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IM Internal Med > Aquifer 1 - Chest Pain > Flashcards

Aquifer 1 - Chest Pain Flashcards

1
Q

List five broad categories of potential causes of chest pain.

A 
Cardiac
GI
Pulmonary 
Musculoskeletal 
Psychogenic
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2
Q

Name 5 cardiac etiologies of chest pain

A

Angina: stable, unstable, or atypical / variant (eg Prinzmetal’s)
Acute MI
Cocaine-induced

Pericarditis

Aortic dissection

Valvular heart disease

Arrythmia

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3
Q

Name 4 GI etiologies of chest pain

A

Esophageal disease (GERD, esophagitis, esophageal dysmotility)

Biliary disease (cholecystitis, cholangitis – typically RUQ with radiation to shoulder, may be referred to chest)

Peptic ulcer disease

Pancreatitis

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4
Q

Name 6 pulmonary etiologies of chest pain

A 
Pneumonia
Spontaneous pneumothorax
Pleuritis
Pulmonary embolism
Pulmonary hypertension/cor pulmonale
Pleural effusion
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5
Q

Name 5 MSK/neuro etiologies of chest pain

A 
Costochondritis
Rib fracture
Myofascial pain syndromes
Muscular strain
Herpes zoster
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6
Q

Name 3 psychiatric etiologies of chest pain

A

Panic disorders
Hyperventilation
Somatoform disorders

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7
Q

What is the management of possible acute coronary syndrome?

A

Aspirin
ECG
Troponins

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8
Q

What is acute coronary syndrome?

A

Any group of Sx consistent with acute myocardial ischemia

So, MI (STEMI or NSTEMI) or unstable angina

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9
Q

In what proportion of patients may an initial ECG be non-diagnostic? What is done as a result?

A

Half

Serial ECGs

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10
Q

When should cardiac biomarkers be done?

A

Initial workup
If negative, also at 6h
If negative, also at 12h

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11
Q

Why are troponins particularly good biomarkers?

A

Very sensitive for MI within last 24h

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12
Q

In which ACS patients would supplemental oxygen be given?

A

NSTE-ACS and one of:

  • arterial oxygen saturation less than 90%
  • respiratory distress
  • other high-risk features of hypoxemia.
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13
Q

What are the STEEEP goals for medicine?

A

Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered

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14
Q

What history should be elicited from patients with suspected ACS?

A

Assoc Sx: nausea, diaphoresis, SOB

Cardiac risk factors

Distinguish ischemic from non-ischemic pain

Remember ACS can present with atypical Sx

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15
Q

Name 5 cardiac risk factors (7 listed)

A 
Smoking
HTN
Dyslipidemia
DM
PMHx or FHx of CAD
peripheral arterial disease
stroke
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16
Q

Name 5 symptoms commonly associated with ACS

A 
SOB
diaphoresis
Belching, nausea, indigestion
dizziness, syncope
weakness, fatigue
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17
Q

What proportion of patients who come to the ED with an MI have the “classic” severe substernal chest pressure.?

A

25%

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18
Q

Name 5 terms pt often use to describe cardiac chest pain (many listed)

A 
Squeezing
tightness
pressure
crushing
constriction
strangling
burning 
heart burn
fullness
band-like sensation
knot in chest
lump in throat
heavy weight on chest
like a bra too tight
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19
Q

What are the features of cardiac chest pain?

A

Diffuse discomfort, difficult to localize; not one specific spot

Radiation: shoulders, arms, neck & throat, lower jaw & teeth (not upper jaw), epigastrium, sometimes back

Exertional; relieved by rest or nitro

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20
Q

What components of the physical exam are important for acute chest pain?

A

Vital signs for tachycardia, hypotension, or hypertension.

Cardiac exam for murmur, S3 or S4 gallop, auscultation and palpation of pulses.

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21
Q

Chest pain and pericardial rub suggest ….

A

Pericarditis

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22
Q

Chest pain and lung crackles suggest …

A

heart failure

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23
Q

Chest pain and fever, crackles, and decreased breath sounds suggest …

A

pneumonia

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24
Q

Chest pain and unilateral leg swelling and/or tenderness suggest …

A

DVT/PE

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25
Q

Chest pain and RUQ tenderness suggest …

A

acute cholecystitis

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26
Q

Chest pain and epigastric discomfort on palpation suggest …

A

GERD

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27
Q

Chest pain and chest wall tenderness suggest …

A

trauma, costochondritis, and other muscular causes of chest pain

Could also be ACS

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28
Q

Chest pain and Pulse and BP differential from side to side suggest …

A

significant peripheral arterial obstruction - including aortic dissection!

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29
Q

Chest pain and diastolic heart murmur suggest …

A

Aortic dissection

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30
Q

Refresh: Guidelines for good summary statements

A

1) Include accurate information and not include misleading information.
2) Facilitate understanding of the primary problem and appropriately narrow the differential diagnosis through the inclusion of pertinent key features. (The aim is to frame understanding of the primary problem rather than to report all information indiscriminately.)
3) Express key findings in qualified medical terminology (e.g., heart rate of 180 beats/minute is tachycardia); synthesize details into unifying medical concepts (e.g., retractions + hypoxia + wheezing = respiratory distress).
4) Use qualitative terms that are more abstract than patient’s signs; these are often binary in nature (e.g., acute vs. chronic; constant vs. intermittent).

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31
Q

What is the pretest probability for CAD in a patient who is male in his late 40’s presenting with exertional substernal chest pain

A

over 90%

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32
Q

What proportion of pt with PE have abnormal ECG?

A

70%

Two most common abnormalities are nonspecific: sinus tachycardia and nonspecific ST and T-wave changes

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33
Q

What uncommon findings on ECG suggest PE?

A

S1Q3T3 (S wave in lead one, Q wave in lead three and inverted T-wave in lead three)
transient right bundle branch block
T-wave inversions in V1-V4.

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34
Q

What is stable angina?

A

symptoms have been occurring chronically and are predictable with exertion. It is thought to be caused by a stable atherosclerotic plaque.

predictable pattern of chest discomfort that usually occurs with exertion or extreme emotion. It is relieved by rest or nitroglycerin in less than 5-10 minutes.

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35
Q

What is unstable angina?

A

chest pain occurs at rest, is new, is increasing in frequency, or when its onset is triggered with a lower level of exertion.

Caused by an unstable plaque that has ruptured and caused a non-occlusive thrombus.

Unstable angina is an acute coronary syndrome (along with non-ST segment elevation myocardial infarction and ST segment elevation myocardial infarction) and requires emergency care.

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36
Q

What is acute MI?

A

results from rupture of an unstable plaque with subsequent occlusive coronary artery thrombosis and myocardial necrosis.

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37
Q

How is MI differentiated from unstable angina?

A

Based on whether troponins increase

No troponin increase = no MI

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38
Q

What are the criteria for acute MI?

A

Rise and fall of troponin or creatine kinase myocardial band (CK-MB) plus ONE of the following:

  • Symptoms consistent with myocardial ischemia
  • Electrocardiogram changes indicating myocardial ischemia (ST-segment elevation or depression)
  • New pathologic Q waves
  • Findings on percutaneous coronary intervention (PCI)
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39
Q

What is a STEMI?

A

acute MI in which the ST segment on the ECG shows elevation typical of myocardial ischemia.

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40
Q

When should STEMI be suspected / triaged?

A

Any patient who presents with a clinical history consistent with acute MI and has a new left-bundle branch block should be triaged as ST-elevation MI (STEMI).

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41
Q

What is the active management of unstable angina?

A 
SL nitroglycerin
Beta blocker
Aspirin
Heparin
Angiography with PCI
Statin (high intensity)
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42
Q

What should be ordered on admission for a pt with unstable angina?

A

Bed rest
PO metoprolol
Continuous cardiac monitoring
Anticoagulation (heparin)

43
Q

Why are beta blockers ordered for MI? (Clinical impact)

A
  • reduce infarct size and the frequency of myocardial ischemia
  • improve short- and long-term survival.

Beta blockers are effective because they decrease myocardial oxygen demand by reducing heart rate, blood pressure, and myocardial contractility. The prolonged diastole may also help to augment myocardial perfusion, which occurs mainly during diastole.

44
Q

Why are beta blockers ordered for MI? (MOA)

A

Decrease myocardial oxygen demand by reducing heart rate, blood pressure, and myocardial contractility.

(The prolonged diastole may also help to augment myocardial perfusion, which occurs mainly during diastole.)

45
Q

Why is continuous cardiac monitoring indicated in suspected MI?

A

Tachyarrhythmias and bradyarrhythmias may occur in the setting of an acute MI

Can then cause reduced CO and exacerbate ischemia –> MI

46
Q

When is morphine used for MI?

A

Morphine is used in patients with ongoing chest pain for analgesia, but it is not needed if there is no current chest pain.

47
Q

The anterior wall of the heart is roughly represented by which ECG leads?

A

leads V1-4

48
Q

The inferior portion of the heart is roughly represented by which ECG leads?

A

leads II, III and AVF

49
Q

The lateral myocardial wall of the heart is roughly represented by which ECG leads?

A

leads I, AVL, V5 and V6

50
Q

What is the management of acute STEMI?

A

Consult cardiology –> cath lab for PCI

Alternately (eg if rural/no cath lab access), thrombolytics

51
Q

What are the contraindications for thrombolytics?

A

Strong suspicion of dissection of the aorta
Pericardial effusion
Active gastrointestinal or other internal bleeding
Brain tumor, arteriovenous malformation, or aneurysm
Ischemic stroke in preceding 6 months (a verified transient ischemic attack (TIA) is an exception)
Previous intracerebral hemorrhage or subarachnoid hemorrhage
Intracranial procedure or recent head trauma
Severe known bleeding disorder: coagulation abnormality, thrombocytopenia, etc.

52
Q

Which artery is usually occluded in an inferior infarction?

A

Right coronary

Inferior infarction is typically associated with a right coronary artery lesion for approximately 90% of the population who possess a right-dominant coronary circulation. Approximately 10% of the population have atypical “left-dominant” or “co-dominant” coronary circulation

53
Q

Which artery is usually occluded in an anterior infarction?

A

Left anterior descending

54
Q

Which artery is usually occluded in a lateral infarction?

A

Circumflex

55
Q

Which artery is usually occluded in an antero-lateral infarction?

A

Proximal left main coronary artery

56
Q

Name 5 complications of MI

A

arrhythmias (bradyarrhythmias and tachyarrhythmias)
reduced ventricular function
cardiogenic shock
papillary muscle dysfunction with acute valvular dysfunction
ventricular free wall rupture
pericarditis
recurrent thrombosis

57
Q

Give an overview of post-cath instructions for a pt with MI

A
  1. early monitoring (2-3d in hosp)
  2. Rest for 1-2w then can return to work; can resume sexual activity 7-10d after discharge
  3. Cardiac rehab
  4. Smoking cessation, diet, lifestyle
58
Q

What are the discharge meds post-MI and cath?

A 
Aspirin
Clopidogrel
Beta blockers
Statins
SL nitro (PRN)
59
Q

What are the SSx & Ix of angina / CAD?

A

Chest pressure that may radiate to neck/arm/shoulder. May have associated dyspnea. Risk factors include obesity, diabetes, hypertension and hyperlipidemia.

May have abnormal blood pressure, lower extremity edema, cardiac murmurs or normal exam.

May have ST segment abnormalities on EKG.

60
Q

What are the SSx & Ix of variant angina?

A

Vasospastic cause of angina, often younger pt with few risk factors. Risk factors include tobacco use.

Between episodes of chest pain physical exam may be completely normal.

Accompanied by transient ST elevation on EKG.

61
Q

What are the SSx & Ix of variant angina?

A

Chest pain after cocaine use from infarction or intense coronary spasm.

Patients may have burn marks on lips and fingers from crack pipe, needle marks on skin from injections, and/or inflammation and ulcerations in the pharynx and nasal septa.

Urine tox screen positive for cocaine and drug metabolites. Elevated CPK levels may be seen with associated rhabdomyolysis.

62
Q

What are the SSx & Ix of aortic dissection?

A

Crushing or tearing quality pain in center of chest, radiates to back.

Murmur of aortic insufficiency may be present.

Widened mediastinum on CXR.

63
Q

What are the SSx of valvular heart disease?

A

Aortic stenosis can result in anginal pain. Mitral prolapse patients often have atypical chest pain.

AS - systolic crescendo decrescendo murmur
MVP - midsystolic click with possible late systolic murmur.

64
Q

What are the SSx & Ix of pericarditis?

A

Severe retrosternal, often pleuritic, pain that varies with body positioning.

Pericardial friction rub.

Diffuse ST elevation and PR depressions on EKG, pericardial effusion on echocardiogram.

65
Q

What are the SSx & Ix of non-ischemic cardiomyopathy?

A

Usually does not manifest as chest pain but rather dyspnea or other CHF symptoms.

Pulmonary edema, hepatic congestion, lower ext edema, jugular venous distension.

Enlarged heart on CXR, elevated b- type naturetic peptide.

66
Q

What are the SSx & Ix of cardiac syndrome X?

A

Exertional angina-like chest pain, more common in women.

Exam normal

Usually normal EKG, abnormal exercise stress test with normal coronaries on angiogram and no evidence of coronary spasm.

67
Q

What are the SSx & Ix of myocarditis?

A

Similar to pericarditis (severe retrosternal, often pleuritic, pain that varies with body positioning) but can also mimic ischemia.

May manifest as CHF.

Cardiac enzymes may be elevated.

68
Q

What are the SSx of esophageal disease (GERD)?

A

Reflux associated chest pain usually occurs after meals, is exacerbated by lying down or bending over, and improved by antacids. May be associated with chronic cough.

May be associated with laryngitis or posterior oropharyngeal erythema in severe cases.

69
Q

What are the SSx & Ix of biliary disease?

A

Usually presents with right upper quadrant or epigastric pain. Pain may be exacerbated by fatty foods and may be accompanied by nausea and/or vomiting.

Murphy’s sign - tender palpable gallbladder with a sudden halt of inspiration with palpation in the upper quadrant. Occasional jaundice

Abnormal liver tests

70
Q

What are the SSx & Ix of peptic ulcer disease?

A

Gnawing, midepigastric pain.

Epigastric tenderness

Ulceration/inflammation seen on endoscopy

71
Q

What are the SSx & Ix of pancreatitis?

A

Moderate to severe midepigastric pain with radiation to the back. May be accompanied by nausea and vomiting.

Epigastric tenderness

Elevated amylase and lipase

72
Q

What are the SSx & Ix of pneumonia?

A

Productive cough, fever

Crackles on lung exam, egophony, whispered pectoriloquy

Infiltrate on CXR, elevated WBC

73
Q

What are the SSx & Ix of spontaneous pneumothorax?

A

Acute pleuritic chest pain and dyspnea

Decreased breath sounds and resonance to percussion in affected hemithorax, possible tachycardia, distended neck veins, and hypotension

Abnormal CXR

74
Q

What are the SSx & Ix of pleuritis?

A

Pleuritic chest pain, dyspnea, possible viral syndrome

Pleural friction rub heard with lung auscultation, small tidal volume breathing

Possible pleural effusion on CXR

75
Q

What are the SSx & Ix of pulmonary embolism?

A

Pleuritic chest pain associated with dyspnea

Tachycardia, hypoxemia, possible right heart strain on EKG

Abnormal CT angiography of chest, V/Q scan, elevated D-dimer

76
Q

What are the SSx & Ix of costochondritis?

A

Sharp anterior chest pain occurring at costochondral and costosternal junctions.

Tenderness to palpation over chest wall.

77
Q

What are the SSx & Ix of rib fracture?

A

Pleuritic chest pain, worsened by movement, often associated trauma

Tender over affected rib

Rib fractures seen on X-ray

78
Q

What are the SSx of myofascial pain syndromes?

A

Widespread pain often with trigger points, often associated depression or sleep disorder

Tender to palpation over trigger points

79
Q

What are the SSx & Ix of muscular strain?

A

Chest pain after excessive exercise or cough

Possible chest wall tenderness

80
Q

What are the SSx & Ix of herpes zoster?

A

Pain and possible itching in a dermatomal pattern

Rash absent initially then characteristic vesicular rash that follows dermatomal distribution, not crossing midline.

81
Q

What are the SSx of panic disorder?

A

Sudden intense anxiety often associated with palpitations, dyspnea

Tachycardia, tachypnea, diaphoresis, and/or tremor

82
Q

What are the SSx & Ix of hyperventilation?

A

Dyspnea, light-headedness, often associated with anxiety

Tachypnea

ABG shows low PCO2

83
Q

What are the SSx of panic disorder?

A

Variety of somatic complaints, can include chest pain. Often history of psychiatric illness

Subjective complaints outnumber objective findings

84
Q

What are the three criteria for typical angina?

A

Substernal chest discomfort with a characteristic duration and features
Provoked by exertion or emotional stress
Relief with rest or nitroglycerin

85
Q

What is atypical angina?

A

CP that meets only 2 of the 3 features of typical angina

86
Q

What is an anginal equivalent?

A

symptom such as shortness of breath, diaphoresis , extreme fatigue, or pain at a site other than the chest, occurring in a patient at high cardiac risk.

Considered to be symptoms of myocardial ischemia.

87
Q

What is non-cardiac chest pain?

A

CP that meets 0 or only 1 of the angina criteria

88
Q

When can angina be considered stable?

A

Consistent pattern (not worsening) for more than 4-6 weeks

89
Q

What are the major risk factors for ASCVD?

A 
age 
male sex
current smoking
dyslipidemia
diabetes
hypertension
90
Q

What is ASCVD?

A

atherosclerotic cardiovascular disease, ie Cardiovascular disease and stroke

91
Q

What primary prevention should be done to prevent CVD?

A

Modifiable risk factors:
avoiding tobacco, aggressively controlling diabetes mellitus, keeping blood pressure and cholesterol in the normal range, and regular exercise.

Some evidence around daily aspirin from age 50-70 but that’s changing (check current guidelines)

92
Q

What secondary prevention should be done to prevent CVD?

A

Target modifiable risk factors more aggressively

  • aspirin and statins are mainstays
  • beta blockers or ACE inhibitors may be used
93
Q

What tests should be done for a patient with suspected stable angina?

A 
ECG
CBC (low Hb)
Metabolic panel (baselines, DM or other etiologies)
TSH
Fasting lipid panel (DLD)
94
Q

Why order a TSH in suspected angina?

A

Hyperactivity of the thyroid can be associated with increased oxygen demands on the heart, while diminished thyroid function may aggravate risk factors such as weight gain and dyslipidemia.

95
Q

Why would you do a CXR for suspected angina?

A

Screen for / r/o non-cardiac causes

96
Q

When is stress testing indicated?

A

For a pt with intermediate probability of CAD
Assessed based on age, sex and symptoms (table in AHA article)

Low: unlikely to be positive
High: stress test won’t r/o so head straight to angio

97
Q

What is the treatment of stable angina?

A

Beta blockers
Calcium channel blockers
Nitrates

98
Q

What are common side effects of lisinopril (ACEi)?

A

cough
renal dysfunction
angioedema
hyperkalemia

99
Q

What are common side effects of hydrochlorathiazide?

A 
dehydration
hyponatremia
hypokalemia
renal dysfunction
increases serum uric acid which may precipitate gouty attack
100
Q

What are common side effects of metoprolol (beta blocker)?

A

hypotension
bradycardia
heart block

101
Q

What are common side effects of clopidogrel?

A

bleeding

102
Q

What are common side effects of aspirin?

A

gastritis
peptic ulcer disease
bleeding (especially when used with clopidogrel)

103
Q

What are common side effects of atorvastatin?

A

rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria
biochemical abnormalities of liver function

Myalgia is a common side effect and sometimes limits compliance.

IM Internal Med (11 decks)

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