Cardiac Cases- Leah (3)

Question 1

Chest Pain General Ddx (5):

Answer 1

• angina/cardiac
• GI/GERD
• pulm (PE, pneumonia)
• musculoskeletal
• anxiety

Question 2

Clue that chest pain is musculoskeletal (2):

Answer 2

• Patient can point to one area of the pain. No radiation.

- Pain is worse in certain position.

Question 3

How do you evaluate chest pain (5 steps)?

Answer 3

1: EKG, lipids, enzymes

2. Stress test (if not in acute danger)
3. CT of chest
4. Heart cath
5. Upper GI series

Question 4

How does an abnormal stress test appear?

Answer 4

• heart appears dark when stressed because vessels cannot dilate in response to stress (the vessels don’t take up dye)
• (usually there are two rows, the top is stressed and the bottom is normal)

If top and bottom rows match, the test is normal.

Question 5

If you are 99% sure that a patient has a cardiac condition, what test can be avoided?

Answer 5

Stress tests.

Definitely because you could KILL THEM if it’s bad enough and you make them do it! So bad!

Question 6

Criteria for typical/ atypical angina:

Answer 6

Typical: 
1. Substernal discomfort (predictable timing/characteristics) 
2. Provoked 
3. Relieved by rest/ NG 
Must meet all three

• Atypical meets 2. If two aren’t met, not cardiac.

Question 7

What does a plaque rupture lead to?

Answer 7

Unstable angina or MI; NOT typical angina/ stable angina.

Question 8

What is supply ischemia?

What is demand ischemia?

Answer 8

TYPICAL angina is demand ischemia. Ischemia only present with increased DEMAND to which vessels cannot respond.

Unstable angina/ prinzmetal angina/ MI are SUPPLY ischemia. Not enough supply regardless of demand.

Question 9

Tip to diagnose MI in someone with history of cardiac conditions:

Answer 9

Ask if pain is similar to past MIs or angioplasty

Question 10

Aortic dissection- what tests should you order?

Answer 10

• GOLD STANDARD: CT w/ contrast
• Will see mid ended mediastinum on X-ray
• If dissection backs up into coronaries, can see changes on EKG

Question 11

Should you stent or intervene during stable angina w/ 90% block?

Answer 11

Nope. It won’t change the outcome.

Question 12

Can you clear someone with stable angina for surgery?

Answer 12

Yes, unless there is something you can do to improve survival.

He has an elevated surgery risk, but you cannot fix that.
Should continue statins perioperatively

Question 13

Atherosclerosis effects what vessels?

Answer 13

Muscular and elastic

Question 14

What 3 causes of chest pain get worse when laying down?

Answer 14

• Pericarditis (Pain)
  -CHF (SOB)

- Reflux

Question 15

Most common catastrophic “misses” in ED: (2)

Answer 15

1. PE

2. aortic dissection

Question 16

Most common site for angina in women?

Most common symptoms (2)?

Answer 16

Between shoulder blades (I’ve heard of “bra feels tight”)

Palpitations, dyspnea

Question 17

What population gets silent MIs?

Answer 17

Diabetics, work them up even with low risk sometimes.

Question 18

What happens when you cath a young, healthy patient?

Answer 18

They aren’t used to ischemia.

They will go into AFIB when your open their coronaries!

Question 19

What do you do for a young patient with chest pain and no other risk factors/ symptoms?

Answer 19

An EKG…..nothing else if it’s Normal and you don’t hear a murmur. (HCOM presents with murmur)
Not stress test. Not heart cath.

Question 20

“What increases survival?” (3 drugs; 2 procedure)

Answer 20

Statins
ASN
B-Blockers
Stents/ Bipass