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LMCC - Medicine > Cardiology - Chest Pain > Flashcards

Cardiology - Chest Pain Flashcards

1
Q

Discuss the typical findings for angina and the CCS classification

A

Angina has all 3 of (atypical only 2):
- Retrosternal chest pain that radiate to shoulder/jaw/arm
- Provoked by exertion or emotional stres
- Improves with rest or nitroglycerin
CCS Classification
- CCS1: No limitation to activity; angina only with strenuous activity
- CCS2: Slight limitation to activity; angina with normal activity
- CCS3: Marked limitations to ordinary activity: angina with walking or climbing stairs
- CCS4: Angina at rest

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2
Q

Discuss the presentation, exam, and management of stable angina

A 
Presentation
- typical angina <20 minutes
Exam
- Dyskinetic apical pulse
- S4
- Mitra regurgitation
Management
- Smoking cessation
- nitrates
- Beta blocker
- Aspirin
- Statin
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3
Q

Discuss the differences between STEMI, NSTEMI and unstable angina

A

Unstable Angina
- severe and prolonged angina >20 with no ECG changes or cardiac enzyme changes
NSTEMI
- severe and prolonged angina >20 minutes with no ECG changes but elevation in cardiac enzymes
STEMI
- severe and prolonged angina >20 minutes with ECG and cardiac enzyme changes

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4
Q

List the stratification for treatment for NSTEMI

A 
High risk (TIMI 5-7, ST shift)
- Heparin
- GP IIb/IIIa inhibitor (abiximab) with ticagralor
- B blocker
- Early catheterization
Intermediate Risk (TIMI 3-4, normal ECG)
- heparin or LMWH
- Clopidegrel
- Observation
Low Risk (Time <=2)
- Beta blocker
- Early follow up
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5
Q

List the Major Risk Factors for Ischemic Heart Disease

A

Major

  • History of cardiovascular disease
  • older age
  • male
  • Dyslipidemia
  • Smoking
  • Diabetes
  • Hypertension
  • Family Hx (male <55, female <65)
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6
Q

Discuss the presentation, investigations and management for Acute coronary syndrome

A

Presentation
- cresendo pattern with increased frequency, intensity and duration of chest pain
- angina at rest without provocation
- new onset severe angion (CCS3) without previous angina
- diaphoresis
- shortness of breath
- nausea
Investigations
- ECG
- inferior (RCA) II, III, aVF
- lateral (LCA, left circumflex) I, aVL, V5, V6
- lateral (LAD) V5, V6
- anterior (LAD) V1, V2, V3, V4
- troponon I at presentation and 6&9 hrs later
- if negative at 6 hrs then rules out infarction
Management
- supplemental oxygen
- anti-platelets (ASA 160 and ticagrelor 180/clopidogreal 600mg)
- anti-thrombin (heparin50-70units/kg 4000U)
- vessels opened by PCI or tPA
- PCA if within 90 minutes to cath lab of first medical contact and <=12h of symptom onsent
- tPA if <=12hr of symptom onset and <30 minute until administration
- tPa dose 30mg <60kg, 35mg 60-69kg, 40mg 70-79kg, 45mg 80-89kg, or 50mg >90kg
- Symptomatic
- morphine
- nitroglycerin (unless inferior infarct noted due to risk of decrease preload and cardiovascular collapse)

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7
Q

List the TIMI score

A
  • age >65
  • > 3 cardiac risk factors
  • known CAD or stenosis >50%
  • aspirin use within 7 days
  • severe angina >=2 episodes within 24hrs
  • ECG ST changes (elevation or depression >0.5mm)
  • elevated cardiac markers
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8
Q

Discuss the pathophysiology and risk factors for aortic dissection

A 
Pathophysiology
- tear in intimal layer where blood flow tears and continus to dissect intimal layer
- lead to rupture of aorta, clot in false lumen which can travel downward and lead to acute ischemia, or cardiac tamponade
Risk Factors
- Hypertension
- Connective tissue disease 
- bicuspid aortic valve
- aortic co-arctation
- valve replacement
- CABG
- Smoking
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9
Q

Discuss the presentation and management of aortic dissection

A

Presentation
- abrupt onset and hemodynamically unstable
- sharp tearing chest pain radiating to the back
- 40% immediate mortality with 1% risk of mortality per hour for next 48hrs
- discrepancy in blood pressure (>20-30mmHg) between two arms
- weak one sided pulse
- aortic regurgitation
Investigation
- CXR show wide mediastinum
- CT angiography
Management
- ABC with IV medication to lower blood pressure
- Type A involve ascending aorta and require surgery
- Type B no involvement of ascending aorta and can be treated with IV labetalol to lower blood pressure

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10
Q

Discuss the pathophysiology, presentation and management for pericarditis

A

Pathophysiology
- Inflammation of the pericardium
- due to Cosackie virus A,B
Presentation
- Triad: chest pain, friction rub and diffuse ST changes with PR depression
- sharp pleuritic chest pain at central or left chest which is worse when lying down
Management
- aspirin, NSAID, steroids if refractory for pericarditis
- colchicine

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11
Q

Discuss the presentation and management of cardiac tamponade

A

Presentation
- Beck triad: hypotension, increased JVP, muffled heart sounds
- pulsus paradoxus (decrease in BP by >10 with inspiration)
- Obstructive shock: increase JVP, x descent only
Investigations
- electrical alternans, low voltage
- echo
Management
- pericardiocentesis for effusion or tamponade
- avoid diuretics and vasodilators

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12
Q

Discuss the pathophysiology and risk factors for a pulmonary embolism

A

Pathophysiology
- clot in deep leg veins which travels to the lungs
- leads to dead space ventilation and hypoxemia
- increased pulmonary vascular resistance causing right ventricular strain
Risk Factors (Virchow’s triad)
- Stasis: immobilization
- Hypercoaguable states: inherited thrombotic disorder, malignancy, inflammatory disorders, pregnancy or OCP
- Endothelial injury

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13
Q

Discuss the presentation and management of pulmonary embolus

A

Presentation
- Pain on one side of chest that is worse with inspiration
- dyspnea, cough, syncope, hemoptysis and palpitation
- increase JVP, peripheral edema
- DVT signs
Investigations
- Wells criteria
- CXR band atelectasis decrease volume on one side
- ECG: right ventricular strain (inverted T wave and ST depression in V1-V4), RBBB, S1Q3T3
- d-dimer positive
- CT pulmonary angiography
Management
- massive PE resulting in cardiovascular compromise then tPA
- stable then low molecular weight heparin and bridge to warfarin

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14
Q

List the Wells criteria for PE

A
  • Active Cancer
  • Hemoptysis
  • Recent immobilization or surgery +1.5
  • Tachycardia (>100bpm) +1.5
  • Past Hx of DVT or PE +1.5
  • Signs or symptoms of DVT +3
  • No alternative diagnosis more like +3
    >4 then high risk and go right to CTPA
  • <4 do D-Dimer first and then if positive move to CTPA
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15
Q

Discuss the discharge criteria for PE

A 
PE Severity Index
- age >80
- Hx of Cancer
- Hx of Heart Failure or chronic lung disease
- Tachycardia >100
- Hypotension where SBP <100
- Hypoxia <90%
High risk if >=1
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16
Q

Discuss esophageal rupture

A 
Risk Factors
- severe vomiting 
- recent upper endoscopic procedure
Presentation
- severe retching followed by extreme retrosternal chest pain
- odynophagia
- neck pain
- dysphonia
- dyspnea
- Fever
Investigations
- leukocytosis
- CXR pneumo-mediastinum, free peritoneal air, subcutaneous emphysema
- CT Chest
Management
- NPO
- IV Abx (Ceftriaxone and Flagyl)
- IV PPI
- Drainage
- Surgery
17
Q

List the criteria for metabolic syndrome

A

Waist circumference >94cm for men or >80cm for women with >=2 of:

  • Hypertriglyceridemia (>1.7)
  • Low HDL (<1 for men, <1.3 for women)
  • Hypertension (>135/85)
  • High fast glucose (>5.6)
18
Q

List the indications for non-invasive testing for those with typical angina

A

Non-invasive testing and rest echocardiogram

  • Adults >30 with >=2 angina criteria
  • Male >40 and female >60 with 1 angina criteria
  • male <40 and female <60 with 1 angina criteria and cardiovascular risk factor
19
Q

Discuss the alogrithm for non-invasive cardiac stress testing

A

Able to Exercise Patients
- Normal ECG
- Exercises stress test
- ECG abnormal but no LBBB or ventricular paced rhythm
- exercise echocardiography
- exercise myocardial perfusion study
- ECG abnormal with LBBB or ventricular paced rhythm
- Vasodilator myocardial perfusion study
Patient Unable to Exercise
- ECG normal
- Dobutamine or vasodilator echocardiography
- ECG abnormal
- Vasodilator myocardial perfusion study
- Cardiac computed tomographic angiography

20
Q

Discuss criteria that preclude ECG cardiac stress testing

A

ECG at rest with any of the following

  • ST depression >0.1mm
  • Digoxin use
  • Wolf-parkinon white syndrome
  • LBBB
  • Ventricular paced rhythm
21
Q

Discuss the indications for angiography

A

Any of the following

  • high pre-test probability of ischemic heart disease (male with >3 angina criteria)
  • High risk features on stress test or left ventricular ejection fraction on echocardiogram
  • history of cardiac arrest
  • life-threatening arrhythmia on ECG
22
Q

Discuss the short term and long term management for angina

A 
Short term
- sublingual nitroglycerin PRN for exertional angina
Long Term
- Beta blockers
     - first line
     - used for those with previous MI or reduced ejection fraction 
     - titrated to resting HR of 55-60
- Dihydropyridine calcium channel blocker 
     - amlodipine
- Long acting nitrate
- Revascularization therapy
       - PCI
       - CABG
23
Q

Discuss the secondary therapy for ischemic heart disease

A

Anti-Platelet Agent
- ASA 81mg PO OD for ischemic heart disease
- Clopidogrel 75mg can be used if patient intolerant to ASA
Renin-Angiotensin Receptor Blocker
- ACEI for patients with ischemic heart disease
- especially if left ventricular ejection fraction <=40%, hypertension, diabetic, or CKD
Beta Blocker
- left ventricular ejection fraction <=40%
- history of MI or acute coronary syndrome
- heart failure
Statin
- all patient with ischemic heart disease no matter lipid profile

24
Q

Discuss tension pneumothorax and its treatment

A
  • air entry via one way valve into pleural cavity resulting in compression of structures in chest
    Signs
  • respiratory distress
  • decreased breath sounds on affected side
  • contralteral tracheal deviation
  • High JVP
  • hypotension
    Treatment
  • 1 14-16 gauge IV into 2nd intercostal space mid-clavicular line on affected side
  • chest tube in 5th intercostal space along anterior axiallary line
25
Q

Discuss open pneumothorax and its treatment

A
  • air entry into pleural cavity and open skin wound
    • result in tension pneumothorax
      Signs
  • deep wound on chest cavity with air going in
    Treatment
  • 3 side occlusive dressing
  • chest tube in 5th intercostal space along anterior axillary line
26
Q

Discuss massive hemothorax and its treatment

A
  • massive amount of blood into pleural space compressing lung and preventing it to expand
    Signs
  • blood visualized on CXR
    Treatment
  • chest tube in 5th intercostal space along posterior axillary border
  • surgical repair
27
Q

Discuss flail chest and its treatment

A
  • > =2 fractures in >=2 spots within each rib of multiple ribs
  • broken ribs do not move with rest of ribcage decreasing breathing efficiency
    Signs
  • asymmetric chest rise noted during physical exam
    Treatment
  • early intubation and ventilation control
28
Q

Discuss the pathophysiology of artherosclerosis

A

Endothelial injury from metabolic syndrome -> leads to monocyte recruitment and increased LDL permeability -> monocytes enter into interstitial space and differentiate to macrophages which take up oxidized LDL to become foam cells (Fatty streak with lipid core of plaque) -> cytokine and growth factors promote smooth muscle cell migration into intima and release matrix to form fibrous plaque

  • Plaque rupture leads to thrombosis
  • hemorrhage lead to lumen narrowing
29
Q

List the Long Term Therapy following ACS

A

Antiplatelet and Anticoagulation
- ASA81mg
- Ticagralor 90mg BID for 1mon up to 9-12mon if stent placed
- Warfarin for 3mon if high risk for thrombus
B-Blocker
- Metoprolol 25-50mg BID
Nitrates
- Alleviate ischemia but no improvement in outcome
ACEi
- Asympatomatic high risk even if LVEF >40%
- symptomatic CHF with LVEF <40%
Aldosterone Antagonist
- if on ACEi and BB with LVEF <40% and CHF or DM
Statis
- Artovastatin 80mg OD

30
Q

Discuss the complications following a STEMI

A

CRASH PAD

  • Cardiac Rupture (LV free wall, papillary muscle, ventricular septum)
  • Arrhythmia
  • Shock
  • Hypertension/Heart Failure
  • Pericarditis (Dresslers Syndrome if 2-8wk following)/PE
  • Aneurysm
  • DVT
31
Q

Discuss the pathophysiology, presentation and management of constrictive pericarditis

A 
Pathophysiology
- fibrosed, thickened, calcified pericardium
- idiopathic
- post-infections
- radiation
Presentation
- dyspnea, fatigue
- Kussmaul sign (increase in JVP with inspiration)
- CHF
- Pericordial knock
Management
- Diuretics, salt restriction
- pericardiectomy

LMCC - Medicine (40 decks)

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