Cardiology - Chest Pain Flashcards
Discuss the typical findings for angina and the CCS classification
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
Discuss the presentation, exam, and management of stable angina
Presentation - typical angina <20 minutes Exam - Dyskinetic apical pulse - S4 - Mitra regurgitation Management - Smoking cessation - nitrates - Beta blocker - Aspirin - Statin
Discuss the differences between STEMI, NSTEMI and unstable angina
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
List the stratification for treatment for NSTEMI
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
List the Major Risk Factors for Ischemic Heart Disease
Major
- History of cardiovascular disease
- older age
- male
- Dyslipidemia
- Smoking
- Diabetes
- Hypertension
- Family Hx (male <55, female <65)
Discuss the presentation, investigations and management for Acute coronary syndrome
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)
List the TIMI score
- 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
Discuss the pathophysiology and risk factors for aortic dissection
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
Discuss the presentation and management of aortic dissection
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
Discuss the pathophysiology, presentation and management for pericarditis
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
Discuss the presentation and management of cardiac tamponade
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
Discuss the pathophysiology and risk factors for a pulmonary embolism
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
Discuss the presentation and management of pulmonary embolus
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
List the Wells criteria for PE
- 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
Discuss the discharge criteria for PE
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
Discuss esophageal rupture
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
List the criteria for metabolic syndrome
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)
List the indications for non-invasive testing for those with typical angina
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
Discuss the alogrithm for non-invasive cardiac stress testing
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
Discuss criteria that preclude ECG cardiac stress testing
ECG at rest with any of the following
- ST depression >0.1mm
- Digoxin use
- Wolf-parkinon white syndrome
- LBBB
- Ventricular paced rhythm
Discuss the indications for angiography
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
Discuss the short term and long term management for angina
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
- CABGDiscuss the secondary therapy for ischemic heart disease
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
Discuss tension pneumothorax and its treatment
- 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
Discuss open pneumothorax and its treatment
- air entry into pleural cavity and open skin wound
- result in tension pneumothorax
Signs
- result in tension pneumothorax
- deep wound on chest cavity with air going in
Treatment - 3 side occlusive dressing
- chest tube in 5th intercostal space along anterior axillary line
Discuss massive hemothorax and its treatment
- 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
Discuss flail chest and its treatment
- > =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
Discuss the pathophysiology of artherosclerosis
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
List the Long Term Therapy following ACS
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
Discuss the complications following a STEMI
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
Discuss the pathophysiology, presentation and management of constrictive pericarditis
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
