Aquifer 1 - Chest Pain Flashcards
List five broad categories of potential causes of chest pain.
Cardiac GI Pulmonary Musculoskeletal Psychogenic
Name 5 cardiac etiologies of chest pain
Angina: stable, unstable, or atypical / variant (eg Prinzmetal’s)
Acute MI
Cocaine-induced
Pericarditis
Aortic dissection
Valvular heart disease
Arrythmia
Name 4 GI etiologies of chest pain
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
Name 6 pulmonary etiologies of chest pain
Pneumonia Spontaneous pneumothorax Pleuritis Pulmonary embolism Pulmonary hypertension/cor pulmonale Pleural effusion
Name 5 MSK/neuro etiologies of chest pain
Costochondritis Rib fracture Myofascial pain syndromes Muscular strain Herpes zoster
Name 3 psychiatric etiologies of chest pain
Panic disorders
Hyperventilation
Somatoform disorders
What is the management of possible acute coronary syndrome?
Aspirin
ECG
Troponins
What is acute coronary syndrome?
Any group of Sx consistent with acute myocardial ischemia
So, MI (STEMI or NSTEMI) or unstable angina
In what proportion of patients may an initial ECG be non-diagnostic? What is done as a result?
Half
Serial ECGs
When should cardiac biomarkers be done?
Initial workup
If negative, also at 6h
If negative, also at 12h
Why are troponins particularly good biomarkers?
Very sensitive for MI within last 24h
In which ACS patients would supplemental oxygen be given?
NSTE-ACS and one of:
- arterial oxygen saturation less than 90%
- respiratory distress
- other high-risk features of hypoxemia.
What are the STEEEP goals for medicine?
Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered
What history should be elicited from patients with suspected ACS?
Assoc Sx: nausea, diaphoresis, SOB
Cardiac risk factors
Distinguish ischemic from non-ischemic pain
Remember ACS can present with atypical Sx
Name 5 cardiac risk factors (7 listed)
Smoking HTN Dyslipidemia DM PMHx or FHx of CAD peripheral arterial disease stroke
Name 5 symptoms commonly associated with ACS
SOB diaphoresis Belching, nausea, indigestion dizziness, syncope weakness, fatigue
What proportion of patients who come to the ED with an MI have the “classic” severe substernal chest pressure.?
25%
Name 5 terms pt often use to describe cardiac chest pain (many listed)
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
What are the features of cardiac chest pain?
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
What components of the physical exam are important for acute chest pain?
Vital signs for tachycardia, hypotension, or hypertension.
Cardiac exam for murmur, S3 or S4 gallop, auscultation and palpation of pulses.
Chest pain and pericardial rub suggest ….
Pericarditis
Chest pain and lung crackles suggest …
heart failure
Chest pain and fever, crackles, and decreased breath sounds suggest …
pneumonia
Chest pain and unilateral leg swelling and/or tenderness suggest …
DVT/PE
Chest pain and RUQ tenderness suggest …
acute cholecystitis
Chest pain and epigastric discomfort on palpation suggest …
GERD
Chest pain and chest wall tenderness suggest …
trauma, costochondritis, and other muscular causes of chest pain
Could also be ACS
Chest pain and Pulse and BP differential from side to side suggest …
significant peripheral arterial obstruction - including aortic dissection!
Chest pain and diastolic heart murmur suggest …
Aortic dissection
Refresh: Guidelines for good summary statements
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).
What is the pretest probability for CAD in a patient who is male in his late 40’s presenting with exertional substernal chest pain
over 90%
What proportion of pt with PE have abnormal ECG?
70%
Two most common abnormalities are nonspecific: sinus tachycardia and nonspecific ST and T-wave changes
What uncommon findings on ECG suggest PE?
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.
What is stable angina?
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.
What is unstable angina?
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.
What is acute MI?
results from rupture of an unstable plaque with subsequent occlusive coronary artery thrombosis and myocardial necrosis.
How is MI differentiated from unstable angina?
Based on whether troponins increase
No troponin increase = no MI
What are the criteria for acute MI?
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)
What is a STEMI?
acute MI in which the ST segment on the ECG shows elevation typical of myocardial ischemia.
When should STEMI be suspected / triaged?
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).
What is the active management of unstable angina?
SL nitroglycerin Beta blocker Aspirin Heparin Angiography with PCI Statin (high intensity)
What should be ordered on admission for a pt with unstable angina?
Bed rest
PO metoprolol
Continuous cardiac monitoring
Anticoagulation (heparin)
Why are beta blockers ordered for MI? (Clinical impact)
- 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.
Why are beta blockers ordered for MI? (MOA)
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.)
Why is continuous cardiac monitoring indicated in suspected MI?
Tachyarrhythmias and bradyarrhythmias may occur in the setting of an acute MI
Can then cause reduced CO and exacerbate ischemia –> MI
When is morphine used for MI?
Morphine is used in patients with ongoing chest pain for analgesia, but it is not needed if there is no current chest pain.
The anterior wall of the heart is roughly represented by which ECG leads?
leads V1-4
The inferior portion of the heart is roughly represented by which ECG leads?
leads II, III and AVF
The lateral myocardial wall of the heart is roughly represented by which ECG leads?
leads I, AVL, V5 and V6
What is the management of acute STEMI?
Consult cardiology –> cath lab for PCI
Alternately (eg if rural/no cath lab access), thrombolytics
What are the contraindications for thrombolytics?
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.
Which artery is usually occluded in an inferior infarction?
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
Which artery is usually occluded in an anterior infarction?
Left anterior descending
Which artery is usually occluded in a lateral infarction?
Circumflex
Which artery is usually occluded in an antero-lateral infarction?
Proximal left main coronary artery
Name 5 complications of MI
arrhythmias (bradyarrhythmias and tachyarrhythmias)
reduced ventricular function
cardiogenic shock
papillary muscle dysfunction with acute valvular dysfunction
ventricular free wall rupture
pericarditis
recurrent thrombosis
Give an overview of post-cath instructions for a pt with MI
- early monitoring (2-3d in hosp)
- Rest for 1-2w then can return to work; can resume sexual activity 7-10d after discharge
- Cardiac rehab
- Smoking cessation, diet, lifestyle
What are the discharge meds post-MI and cath?
Aspirin Clopidogrel Beta blockers Statins SL nitro (PRN)
What are the SSx & Ix of angina / CAD?
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.
What are the SSx & Ix of variant angina?
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.
What are the SSx & Ix of variant angina?
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.
What are the SSx & Ix of aortic dissection?
Crushing or tearing quality pain in center of chest, radiates to back.
Murmur of aortic insufficiency may be present.
Widened mediastinum on CXR.
What are the SSx of valvular heart disease?
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.
What are the SSx & Ix of pericarditis?
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.
What are the SSx & Ix of non-ischemic cardiomyopathy?
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.
What are the SSx & Ix of cardiac syndrome X?
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.
What are the SSx & Ix of myocarditis?
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.
What are the SSx of esophageal disease (GERD)?
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.
What are the SSx & Ix of biliary disease?
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
What are the SSx & Ix of peptic ulcer disease?
Gnawing, midepigastric pain.
Epigastric tenderness
Ulceration/inflammation seen on endoscopy
What are the SSx & Ix of pancreatitis?
Moderate to severe midepigastric pain with radiation to the back. May be accompanied by nausea and vomiting.
Epigastric tenderness
Elevated amylase and lipase
What are the SSx & Ix of pneumonia?
Productive cough, fever
Crackles on lung exam, egophony, whispered pectoriloquy
Infiltrate on CXR, elevated WBC
What are the SSx & Ix of spontaneous pneumothorax?
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
What are the SSx & Ix of pleuritis?
Pleuritic chest pain, dyspnea, possible viral syndrome
Pleural friction rub heard with lung auscultation, small tidal volume breathing
Possible pleural effusion on CXR
What are the SSx & Ix of pulmonary embolism?
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
What are the SSx & Ix of costochondritis?
Sharp anterior chest pain occurring at costochondral and costosternal junctions.
Tenderness to palpation over chest wall.
What are the SSx & Ix of rib fracture?
Pleuritic chest pain, worsened by movement, often associated trauma
Tender over affected rib
Rib fractures seen on X-ray
What are the SSx of myofascial pain syndromes?
Widespread pain often with trigger points, often associated depression or sleep disorder
Tender to palpation over trigger points
What are the SSx & Ix of muscular strain?
Chest pain after excessive exercise or cough
Possible chest wall tenderness
What are the SSx & Ix of herpes zoster?
Pain and possible itching in a dermatomal pattern
Rash absent initially then characteristic vesicular rash that follows dermatomal distribution, not crossing midline.
What are the SSx of panic disorder?
Sudden intense anxiety often associated with palpitations, dyspnea
Tachycardia, tachypnea, diaphoresis, and/or tremor
What are the SSx & Ix of hyperventilation?
Dyspnea, light-headedness, often associated with anxiety
Tachypnea
ABG shows low PCO2
What are the SSx of panic disorder?
Variety of somatic complaints, can include chest pain. Often history of psychiatric illness
Subjective complaints outnumber objective findings
What are the three criteria for typical angina?
Substernal chest discomfort with a characteristic duration and features
Provoked by exertion or emotional stress
Relief with rest or nitroglycerin
What is atypical angina?
CP that meets only 2 of the 3 features of typical angina
What is an anginal equivalent?
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.
What is non-cardiac chest pain?
CP that meets 0 or only 1 of the angina criteria
When can angina be considered stable?
Consistent pattern (not worsening) for more than 4-6 weeks
What are the major risk factors for ASCVD?
age male sex current smoking dyslipidemia diabetes hypertension
What is ASCVD?
atherosclerotic cardiovascular disease, ie Cardiovascular disease and stroke
What primary prevention should be done to prevent CVD?
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)
What secondary prevention should be done to prevent CVD?
Target modifiable risk factors more aggressively
- aspirin and statins are mainstays
- beta blockers or ACE inhibitors may be used
What tests should be done for a patient with suspected stable angina?
ECG CBC (low Hb) Metabolic panel (baselines, DM or other etiologies) TSH Fasting lipid panel (DLD)
Why order a TSH in suspected angina?
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.
Why would you do a CXR for suspected angina?
Screen for / r/o non-cardiac causes
When is stress testing indicated?
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
What is the treatment of stable angina?
Beta blockers
Calcium channel blockers
Nitrates
What are common side effects of lisinopril (ACEi)?
cough
renal dysfunction
angioedema
hyperkalemia
What are common side effects of hydrochlorathiazide?
dehydration hyponatremia hypokalemia renal dysfunction increases serum uric acid which may precipitate gouty attack
What are common side effects of metoprolol (beta blocker)?
hypotension
bradycardia
heart block
What are common side effects of clopidogrel?
bleeding
What are common side effects of aspirin?
gastritis
peptic ulcer disease
bleeding (especially when used with clopidogrel)
What are common side effects of atorvastatin?
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.
