Approach to Chest Pain

Question 1

Non-Emergent Chest Pain

Answer 1

Musculoskeletal (costrochondritis)
GI (reflux esoph.)
Cardiac (stable angina, MI)
Psychiatric
Pulmonary
Other

Question 2

Killer Chest Pains

Answer 2

Acute Coronary Syndrome
Pulmonary Embolism
Aortic Dissection
Tension Pneumothorax

Question 3

Common Cardiac Causes of Chest Pain

Answer 3

Angina
MI
Aortic valve disease
Hypertrophic or congestive cardiomyopathy
Aortic dissection
Pericarditis
Mitral valve prolapse

Question 4

Angina Pectoris

Answer 4

After eating, cold weather, carrying weight,w alking up stairs
Substernal chest pain with pain radiating left down the arm

Question 5

Physical Signs in Acute CAD

Answer 5

Pallor
Sweating
Anxiety
Tachycardia
Rise in blood pressure
S4 gallop (stiff heart ventricle)
Mitral regurgitation murmur
Paradoxically split S2
Pulsus alternans

Question 6

Acute Coronary Syndrome

Answer 6

Unstable angina
NSTEMI
STEMI
Give these patients anti-inflammatories and statins

Question 7

EKG Features of Acute Infarction

Answer 7

Elevated ST segments
Inverted T waves
Development of Q waves (within 12 hours)

Question 8

EKG Imposters

Answer 8

Pericarditis
J-Point elevation
W-P-W Syndrome

Question 9

EKG Limitations

Answer 9

LBBB
Permanent pacemaker
Posterior infarction: reciprocal changes in anterior leads (depressed ST segments, tall upright T wave, prominent R waves)

Question 10

Troponin

Answer 10

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

Question 11

Stable Angina

Answer 11

Occurs at a predictable amount of energy expenditure or emotion
Goes away with sublingual nitro

Question 12

Stress Testing

Answer 12

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

Question 13

Pericarditis

Answer 13

Continuous chest pain and fever
Feels better when standing or sitting forward (lets heart hang)
ST Elevation everywhere

Question 14

Aortic Stenosis

Answer 14

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)

Question 15

IHSS

Answer 15

Idiopathic hypertrophic subaortic stenosis
Marked LVH with asymmetrical hypertrophy of IV septum
Dynamic obstruction of LV outflow
Myocardial fiber disarray

Question 16

Noncardiac causes of chest pain

GI

Answer 16

GERD
Diffuse esophageal spasm
Cholecystitis and cholelithiasis

Question 17

Noncardiac causes of chest pain

Pulmonary

Answer 17

Pulmonary hypertension
Pneumothorax
Pulmonary embolism

Question 18

Noncardiac causes of chest pain

Emotional

Answer 18

Anxiety states (hyperventilation)
Depression

Question 19

Noncardiac causes of chest pain

Neuromusclar

Answer 19

Herpes zoster
Cervical arthritis
Chest wall pain and tenderness

Question 20

Aortic Dissection

Answer 20

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)

Question 21

Pulmonary Embolism

Answer 21

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

Question 22

Pneumothorax

Answer 22

Air in plural space
Spontenous
Tension pneumo can be fatal

Question 23

Tension pneumothorax

Answer 23

Progressive deterioration of a simple pneumothorax
Formation of one-way valve at the point of rupture
Complete collapse of the lung