B P5 C35 Approach to the Patient with Chest Pain

Question 1

Only ___________ of patients with acute chest pain actually have ACS

Answer 1

10% to 15%

Question 2

The most common serious cause of acute chest discomfort is ______________

Answer 2

Myocardial ischemia or infarction

Question 3

The classic manifestation of ischemia is ___________

Answer 3

Angina

described as a heavy chest pressure or squeezing, a burning feeling, or difficulty breathing. The discomfort often radiates to the left shoulder, neck, or arm. It typically builds in intensity over a period of a few minutes. The pain may begin with exercise or psychological stress, but ACS most commonly occurs without obvious precipitating factors.

Question 4

The following pain descriptions uncharacteristic of myocardial ischemia:

Answer 4

Pleuritic pain (i.e., sharp or knifelike pain brought on by r tory movements or coughing)

Primary or sole location of the discomfort in the middle or lower abdominal region

Pain that may be localized by the tip of one finger, particularly over the left ventricular apex

Pain reproduced with movement or palpation of the chest wall or arms

Constant pain that persists for many hours

Very brief episodes of pain that last a few seconds or less

Pain that radiates into the lower extremities

Question 5

Clinicians should be mindful of “angina equivalents” such as

Answer 5

Jaw or shoulder pain in the absence of chest pain or dyspnea, nausea or vomiting, and diaphoresis

Women, older persons, and individuals with d betes may experience atypical symptoms of myocardial ischemia or infarction

Question 6

The visceral surface of the pericardium is insensitive to pain, as is most of the parietal surface. Therefore, _____ causes of pericarditis usually cause little or no pain

Answer 6

Noninfectious

Question 7

In contrast, infectious pericarditis almost always involves the surrounding pleura, so patients typically experience pleuritic pain with breathing, coughing, and changes in position. _____ may induce the pain because of the proximity of the esophagus to the posterior portion of the heart.

Answer 7

Swallowing

Question 8

Because the central diaphragm receives its sensory supply from the _____, which in turn arises from the _____ cervical segments of the spinal cord, pain from infectious pericarditis is frequently felt in the shoulders and neck. Involvement of the diaphragm more laterally can lead to symptoms in the upper part of the abdomen and back, and thus create confusion with pancreatitis or cholecystitis.

Answer 8

Phrenic nerve

3rd - 5th cervical segments

Question 9

_________________ causes a sudden onset of excruciating ripping pain, the location of which reflects the site and progression.

Answer 9

Acute aortic dissection

Question 10

_____ aortic dissection manifests as pain in the midline of the anterior aspect of the chest, and posterior descending aortic dissection causes pain in the back of the chest.

Answer 10

Ascending

Question 11

Aortic dissections are rare, with an estimated annual incidence of 3 per 100,000, and usually occur in the presence of risk factors, including _____ (for proximal dissections), and _____ (for distal dissections)

Answer 11

Proximal:
Marfan and Ehlers-Danlos syndromes
BAV
Pregnancy

Distal:
Hypertension

Question 12

Emboli that lead to _____ can cause lateral pleuritic chest pain.

Answer 12

Pulmonary infarction

Question 13

_____ tends to be associated with a burning midline pain, whereas _____ can cause pain over the involved lung

Answer 13

Tracheobronchitis

Pneumonia

Question 14

The pain in pneumothorax begins suddenly and is usually associated with dyspnea. ______ pneumothorax typically occurs in tall, thin young men; _____ pneumothorax occurs in the setting of pulmonary disease such as chronic obstructive pulmonary disease, asthma, or cystic fibrosis.

Answer 14

Primary

Secondary

Question 15

Irritation of the esophagus by _____ can produce a burning dis- comfort that may be exacerbated by intake of alcohol, aspirin, and some foods. Symptoms are often worsened by a recumbent position and are relieved by sitting upright and with acid-reducing therapies.

Answer 15

Acid reflux

Question 16

_____ of the esophagus can occur in patients who have had prolonged vomiting episodes. Severe vomiting can also result in _____with mediastinitis.

Answer 16

Mallory-Weiss tears

Esophageal rupture (Boerhaave syndrome)

Question 17

Chest pain caused by _____ usually occurs 60 to 90 minutes after meals and typically responds rapidly to acid- reducing therapies.This pain is generally epigastric in location but can radiate to the chest and shoulders

Answer 17

Peptic ulcer disease

Question 18

_____ causes a wide range of pain syndromes and generally causes right upper quadrant abdominal pain, but chest and back pain is not unusual. The pain is frequently described as aching or colicky.

Answer 18

Cholecystitis

Question 19

_____ typically causes an intense, aching epigastric pain that may radiate to the back, with limited relief through acid-reducing therapies

Answer 19

Pancreatitis

Question 20

Chest pain secondary to _____ is often elicited by direct pressure over the affected area or by movement of the patient’s neck.2The pain itself can be fleeting, or it can be a dull ache that lasts for hours

Answer 20

Musculoskeletal causes

Question 21

_____ is a major cause of chest discomfort in ED patients. The symptoms typically include chest tightness, often accompanied by shortness of breath and a sense of anxiety, and generally last 30 minutes or longer.

Answer 21

Panic syndrome

Question 22

When evaluating patients with acute chest pain, clinicians must address a series of issues related to prognosis and immediate management. Even before arriving at a definite diagnosis, high-priority questions include the following:

Answer 22

Clinical stability: Does the patient need immediate treatment for actual or impending circulatory collapse or respiratory insufficiency?

Immediate prognosis: If the patient is currently clinically stable, what is the risk that a life-threatening condition such as ACS, PE, or aortic dissection exists?

Safety of triage options: If the risk for a life-threatening condition is low, is it safe to discharge the patient for outpatient management, or should further testing or observation to guide management be undertaken?

Question 23

Guide- lines from the ACC/AHA and European Society of Cardiology (ESC)2,24 emphasize that patients with symptoms consistent with ACS should not be evaluated solely on the phone but should be referred to facilities to be evaluated by a physician and undergo a _____.

Answer 23

12-lead electrocardiogram (ECG)

Question 24

These guidelines also recommend strong consideration of immediate referral to an ED or a specialized chest pain unit for patients with suspected ACS who experience _____.

Transport as a passenger in a private vehicle is considered an acceptable alternative to an emergency vehicle only if the wait would lead to a delay longer than _____ minutes.

Answer 24

Chest discomfort at rest for longer than 20 minutes
Hemodynamic instability
Recent syncope or near-syncope

20-30 mins

Question 25

Patients with the following chief complaints should undergo immediate assessment by triage nurses and be referred for further evaluation:

Answer 25

Chest pain, pressure, tightness, or heaviness; pain that radiates to the neck, jaw, shoulders, back, or one or both arms

Indigestion or heartburn; nausea and/or vomiting associated
with chest discomfort

Persistent shortness of breath

Weakness, dizziness, lightheadedness, or loss of consciousness

Question 26

In one analysis with over 54,000 patients, after adjusting for baseline differences, women were ___% less likely to be reviewed within 10 minutes and ___% less likely to be evaluated within an hour presentation. Such observations underscore the need for more systematic and unbiased approaches to initially evaluate chest pain.

Answer 26

18% - less likely to be reviewed within 10 mins

16% - less likely to be evaluated within 1 hr

Question 27

Chest pain descriptor with the highest positive likelihood ratio for MI

Answer 27

Radiation to the right arm or shoulder (4.7)

Question 28

ECG finding with the highest likelihood for MI

Answer 28

Any ST-segment elevation

Question 29

For patients with ongoing chest discomfort, an ECG, which is a source of decisive data, should be obtained within _____ minutes after arrival, and as rapidly as possible for patients who have a history of chest discomfort consistent with ACS but whose discomfort has resolved by the time of evaluation so that patients who might benefit from immediate reperfusion therapy (mechanical or pharmacologic) can be identified

Answer 29

10 mins

Question 30

The ECG aids in both diagnosis and prognosis. ST segment elevation at least ____ mm in at least2 contiguous leads is required for the diagnosis of STEMI.

ST segment depression as little as _____ mm is suggestive of ischemia.

T wave inversions of at least ____mm can also indicate ischemia but are less specific.

Answer 30

ST elevation: 1 mm

ST depression: 0.5 mm

T wave inversion: 2 mm

Question 31

Completely normal findings on an ECG do not exclude the possibility of ACS; the risk for acute MI is approximately _____% in patients with a history of CAD and _____% in those with no such history.

Answer 31

4% - with history of CAD

2% - no history of CAD

Patients with normal or nearly normal findings on an ECG, however, have a better prognosis than do those with clearly abnormal ECGs at initial evaluation

Question 32

Moreover, a normal ECG has a negative predictive value of _____%,regardless of whether the patient was experiencing chest pain at the time that the ECG was obtained

Answer 32

80% to 90% NPV

Question 33

Diffuse ST-segment elevation and PR-segment depression suggest _____.

Answer 33

Pericarditis

Question 34

_____ suggest PE (ECG)

Answer 34

Right-axis deviation
Right bundle branch block
T wave inversions in leads V1 to V4
S wave in lead I and Q wave and T wave inversions in lead III

Question 35

The _____ specificity of cardiac troponins for myocardium rarely gives false-positive increases (i.e.,increase in the absence of myocardial injury).

Rather, elevations in the absence of other clinical data consistent with ACS usually represent true myocardial dam- age from causes other than atherosclerotic plaque rupture

Answer 35

High specificity

Question 36

_____ MI occurs when there is clinical evidence of myocardial ischemia and an elevated biomarker of necrosis, but in the setting of stable coronary disease with either reduced myocardial oxygen supply (e.g., hypotension, vasospasm, severe anemia) or increased myocardial oxygen demand (e.g., hypertensive crisis, tachycardia, critical aortic stenosis, severe hypertrophic cardiomyopathy, extreme exercise)

Answer 36

Type 2

Question 37

Sex may have a modest effect on hs-cTn concentrations (approximately ___%) although other factors such as age and renal dysfunction likely have greater impact (approximately ____% in healthy individuals). Sex-specific cutpoints have been examined for troponin assays. Studies evaluating sex-specific cutpoints including lower concentrations for women have found that such an approach may double the diagnosis of MI in women; however, the impact on outcomes of this approach is unclear.

Answer 37

40%

300%

Question 38

Importantly, routine application of biomarkers to both men and women presenting with chest pain is also critical, with one study showing that women presenting with acute chest pain were ___% less likely than men to have a troponin test performed and were also less likely to be admitted to a specialized care unit and more likely to die

Answer 38

20%

Question 39

Preferred diagnostic biomarker for AMI

Answer 39

Cardiac troponin

The high specificity of cardiac troponins for m dium rarely gives false-positive increases (i.e., increase in the absence of myocardial injury). Rather, elevations in the absence of other clinical data consistent with ACS usually represent true myocardial damage from causes other than atherosclerotic plaque rupture.

Type 2 MI occurs when there is clinical evidence of myocardial ischemia and an elevated biomarker of necrosis, but in the setting of stable coronary disease with either reduced myocardial oxygen supply (e.g., hypotension, vasospasm, severe anemia) or increased myocardial oxygen demand (e.g., hypertensive crisis, tachycardia, critical aortic stenosis, severe hypertrophic cardiomyopathy, extreme exercise).

Question 40

_______________relative lack of specificity because it can be found in the skeletal muscle, tongue, diaphragm, small intestine, uterus, and prostate

Answer 40

CK MB

Question 41

Patients with a ____________________ of ACS should not undergo biomarker measurements because false-positive results could lead to unnecessary hospitalizations, tests, procedures, and complications

Answer 41

Very low probability

Question 42

European and U.S. guidelines are integrating the advantages of hs-cTn assays, with testing regimens that include measurements at presentation and _____ hours later, and examining both the absolute levels and change over time

Answer 42

1-2 hrs

Question 43

In some algorithms, a patient with a very low concentration (generally below the limit of detection) can be ruled out with a single hs-cTn measurement at least _____ hours after the onset of chest pain, whereas patients with a low concentration (assay-dependent but generally at or below the 99th percentile upper-reference limit) at baseline require a second sample but can be ruled out in the absence of changes meeting criteria for dynamic injury _____ hours later.

Answer 43

3 hours

1-2 hours

Question 44

In centers where high-sensitivity assays are not available, serial testing at presentation, and ____________ hours remains the standard of care.

Answer 44

3 - 6 hours

In some algorithms, a patient with a very low concentration (generally below the limit of detection) can be ruled out with a single hs-cTn measurement at least 3 hours after the onset of chest pain, whereas patients with a low concentration (assay-dependent but generally at or below the 99th percentile upper-reference limit) at baseline require a second sample but can be ruled out in the absence of changes meeting criteria for dynamic injury 1 or 2 hours later.

Question 45

Components of TIMI risk score for Unstable Angina/NSTEMI

Answer 45

ABCDE

Age >/= 65 years
Aspirin use in the last 7 days
Angina, severe (>/= 2 episodes in 24 hours)
Biomarker - positive cardiac marker
Coronary risk factors >/= 3
CAD - stenosis >/= 50%
Deviation - ECG ST deviation >/= 0.5

Question 46

Components of HEART score

Answer 46

History
ECG
Age
Risk factors
Troponin

Question 47

A subsequent evaluation of the HEART score and serial high-sensitivity troponin measurements at 0 and 3 hours in patients presenting with suspected ACS (HEART pathway) decreased testing at 30 days by ____%, decreased length of stay by ___ hours, and increased early discharges by ___%

Answer 47

12.1%: Decrease in testing

12 hours: Decrease in length of stay

21%: Increase in early discharge

Question 48

Patients with _____are at extremely low risk of adverse cardiovascular events and can be discharged

Answer 48

Normal troponin levels
No ECG abnormalities concerning for ischemia
TIMI Risk Score of 0
HEART score of 3 or below

Question 49

Noninvasive testing is reasonable in patients without biochemical or ECG evidence of ischemia but who are not at very low risk.Outpatient stress testing is a reasonable option if the patient is at low risk for ACS and if the testing can be accomplished within ___ hours; such a strategy has been shown to be safe.

Answer 49

72 hours

Question 50

True or False

Patients with normal troponin levels, no ECG abnormalities concerning for ischemia and a TIMI Risk Score of 0, or a History, Electrocardiogram, Age, Risk factors, and initial Troponin (HEART) score of ≤3 are at extremely low risk of adverse cardiovascular events and can be discharged.

Answer 50

True

Question 51

Outpatient stress testing is a reasonable option if the patient is at low risk for ACS and if the testing can be accomplished within _________

Answer 51

72 hours

Noninvasive testing is reasonable in patients without biochemical or ECG evidence of ischemia but who are not at very low risk.

Question 52

Give the Indications for Exercise Electrocardiographic Testing in the Emergency Department (ED):

Answer 52

No evidence of myocardial injury by serial troponin (see section on biomarkers)

ECG at the time of arrival and preexercise 12-lead ECG show no significant abnormality

Absence of rest electrocardiographic abnormalities that would preclude accurate assessment of the exercise ECG

From admission to the time that results are available from the second set of cardiac enzymes: patient asymptomatic, lessening chest pain symptoms, or persistent atypical symptoms

Absence of ischemic chest pain at the time of exercise testing

Question 53

Give the contraindications to exercise testing in the ED

Answer 53

New or evolving electrocardiographic abnormalities on the rest tracing

Abnormal cardiac enzyme levels

Inability to perform exercise

Worsening or persistent ischemic chest pain symptoms from admission to the time of exercise testing

Clinical risk profiling indicating that imminent coronary angiography is likely

Question 54

Multiple studies have demonstrated that in low-risk patients, exercise testing is safe and has a negative predictive value of typically greater than ___%, although the positive predictive value is frequently less than ___% (depending on the prevalence of ACS in the tested population)

Answer 54

99%

50%

Question 55

For low-risk patients with no evidence of myocardial ischemia after serial ECGs and biomarkers, outpatient stress testing ideally within ____ hours, and no later than 72 hours, is safe.

Answer 55

24 hours

72 hours

Question 56

High-risk rest perfusion scans are associated with an increased risk for major cardiac complications, whereas patients with low-risk scans have low 30-day cardiac event rates (<____%)

Answer 56

<2%

Question 57

The sensitivity of stress echocardiography appears to be comparable to that of myocardial perfusion imaging (_____%), and its specificity is somewhat better (_____% versus 75% to 90%).

Answer 57

MPI:
Sensitivity: 85-90%
Specificity: 90-95%

Question 58

Myocardial contrast- enhanced echocardiography using microbubble imaging agents offers reasonable (77%) concordance with radionuclide scanning, and the combination of regional wall motion abnormalities and reduced myocardial perfusion has a sensitivity of _____% and a specificity of ____% for ACS

Answer 58

Sensitivity: 80-90%
Specificity: 60-90%

Question 59

In a study that used cardiac MRI to quantify myocardial perfusion, ventricular function, and hyperenhancement in patients with chest pain, the sensitivity for ACS was ___% and the specificity was ___%.

The addition of T2-weighted imaging, which can detect myocardial edema and thus help differentiate acute from chronic per- fusion defects, improves the specificity to 96% without sacrificing sensitivity.

Answer 59

MRI:
Sensitivity: 84%
Specificity: 85%

Addition of T2WI
Specificity: 96%

Question 60

Using multidetector computed tomography, coronary CTA has a sensitivity of greater than __% and a specificity of___% for coronary stenosis greater than 50%

Answer 60

Sensitivity: >90%
Specificity: 65-90%

Question 61

An observational cohort study evaluated the combination of _____ relative to conventional troponin and CCTA looking at traditional features of CAD (no CAD, nonobstructive CAD, 50% stenosis) and found greater diagnostic accuracy for ACS using high-sensitivity troponin and advanced CTA assessment.

Answer 61

hs-cTn at presentation

and

CCTA looking at advanced features of CAD (50% stenosis, high-risk plaque features: positive remodeling, low <30-Hounsfield units plaque, napkin- ring sign, spotty calcium)

Question 62

Another advantage of CTA is that it is often the test of choice for PE and for aortic dissection, and thus so-called _____ CTA can be performed to evaluate coronary disease, PE, and aortic dissection

Answer 62

Triple-rule-out