CHAPTER 48: Chest Pain Flashcards
Is the recent onset of pain, pressure, or tightness in the anterior thorax between the xiphoid, suprasternal notch, and both midaxillary lines
Acute chest pain
Approximately —?—% of patients with AMIs are not diagnosed on initial presentation to the ED
Approximately 2%
Is defined by myocardial necrosis with elevation of cardiac biomarkers and is classified by ECG findings
Acute myocardial infarction (AMI)
Is a clinical diagnosis defined by chest pain or an equivalent (neck or upper extremity pain) from inadequate myocardial perfusion that is new, occurring with greater frequency, less activity, or at rest
Unstable Angina (UA)
Pain which is easily described, precisely located, and often experienced as a sharp sensation
Somatic pain
Somatic = S = Sakto
Pain which is generally more difficult to describe and imprecisely localized
Visceral pain
Pain more likely described as discomfort, heaviness, pressure, tightness, or aching
Visceral pain
Initiate cardiac monitoring and IV access, and obtain an ECG, ideally within —?— minutes of arrival
within 10 minutes of arrival
In patients complaining of chest pain, administer oxygen if ambient saturation is —?—%
<94%
Is a feeling of retrosternal left anterior chest crushing, squeezing, tightness, or pressure
Classic cardiac chest pain
The Multicenter Chest Pain Study reported that —?—% of patients with AMI described their chest pain as sharp or stabbing
22%
Group of patients with ACS who are more likely to present with pain unrelated to exercise, not relieved by rest or nitroglycerin, relieved by antacids, palpitations w/o chest pain, or a chief complaint of fatigue
Pre- & early menopausal women
Nonclassic presentations of acute coronary syndrome occur more frequently in these patient groups
Women Racial minorities AMS Psychiatric disease Elderly Diabetics
WRAPED
Common associated symptom of chest pain in FEMALES
Nausea, Emesis, Jaw pain, Neck pain, & Back pain
Common associated symptom of chest pain in MALES
Diaphoresis
Raise suspicion for ACS in patients complaining of epigastric or upper abdominal discomfort, especially for patients —?— years old or those with known CAD
> 50 years old
Age >40 y/o Male or postmenopausal female HTN Tobacco use Hypercholesterolemia Diabetes Truncal obesity FMHx Sedentary lifestyle
Major risk factors for CAD
Is associated with AMI even in young people with minimal or no CAD
Cocaine use
Are the historical features most strongly associated with ACS
Radiation to the arms and shoulders
Exertional chest pain
TRUE or FALSE?
Lack of exertional pain or pain radiation has no diagnostic value for exclusion of ACS.
TRUE
Lack of exertional pain or pain radiation has no diagnostic value for exclusion of ACS.
Physical examination findings most strongly associated with AMI in patients presenting with acute chest pain
Hypotension
S3 gallop
Diaphoresis
Reproducible chest wall tenderness suggesting a musculoskeletal etiology, is reported in up to —?—% of patients with confirmed AMI
up to 15%
Is the test of choice and is highly sensitive for the detection of large to medium-sized PEs
CT pulmonary angiography
Pain from this condition is classically described as a ripping or tearing sensation radiating to the interscapular area of the back
Aortic dissection
Patients classically present with a history of sudden-onset sharp substernal chest pain following forceful vomiting
Esophageal rupture (Boerhaave’s Syndrome)
Audible crepitus that varies with the heartbeat on auscultation of the precordium, is a rare finding associated with pneumomediastinum
Hamman’s crunch
Approximately —?—% of patients with a spontaneous pneumothorax may develop a tension pneumothorax
Approximately 1% to 3%
Pain from this condition is classically described as a sharp, severe, constant pain with a substernal location
Acute Pericarditis
Is the most specific physical exam finding in acute pericarditis but is not always evident
Pericardial friction rub
Pain in this condition is characterized by sharp,highly localized, & positional pain
Musculoskeletal or chest wall
Is an inflammation of the costal cartilages or their sternal articulations and causes chest pain that is variably sharp, dull, and often increased with respirations
Costochondritis (Tietze’s syndrome)
Is an inflammation of the xiphoid process that causes sharp, pleuritic chest pain reproduced by light palpation
Xiphodynia
Is a short, lancinating chest pain occurring in bunches lasting 1 to 2 minutes near the cardiac apex and is associated with inspiration, poor posture, and inactivity
Precordial catch syndrome (Texidor twinge)
Is an inflammation of the parietal pleura resulting in sharp pleuritic chest pain
Pleurisy
Disorder that typically produce burning or gnawing pain in the lower half of the chest, with a brackish or acidic taste in the back of the mouth
Gastritis & esophageal reflux
Is classically described as a postprandial, dull, boring pain in the epigastric region; Patients often describe being awakened from sleep by discomfort.
Peptic ulcer disease (PUD)
Pain relieved after eating food
Duodenal ulcer pain
Pain exacerbated by eating
Gastric ulcer pain
Typically present with right upper quadrant or epigastric pain and tenderness but can also cause chest pain
Acute pancreatitis & biliary disease
Is often associated with reflux disease and is characterized by a sudden onset of dull or tight substernal chest pain
Esophageal spasm
Pain frequently precipitated by consumption of hot or cold liquids or a large food bolus and may be relieved by nitroglycerin
Esophageal spasm
Is characterized by recurrent, unexpected, and discrete periods of intense fear or discomfort
W/ at least 4 of the ff Sx: chest pain, dyspnea, palpitations, diaphoresis, nausea, tremor, choking, dizziness, fear of losing control or dying, paresthesias, chills, or hot flashes
Panic disorder
About —?— % of the patients identified as having panic disorder were ultimately diagnosed with ACS
9%
Is the imaging test commonly performed in the evaluation of ED patients with chest pain
Chest radiography
Guidelines recommend a screening ECG within —?— minutes of ED arrival in patients with chest pain or other symptoms concerning for ACS
within 10 minutes
TRUE or FALSE?
A normal ECG has the sensitivity to exclude ACS.
FALSE
A normal ECG lacks the sensitivity to exclude ACS, notably unstable angina or NSTEMI.
Among young patients w/out known CAD, a normal ECG is assoc with a cardiovascular event rate of —?—% at 30 days
<1% at 30 days
For high concern for ACS, the ECG should be repeated at —?—minute intervals and compared to prior ECGs
15 to 30-minute intervals
Are proteins essential to cardiac muscle contraction that are complexed w/ actin and myosin filaments w/in cardiac myofibrils and are present w/in cardiac myocyte cytoplasm
Cardiac troponins (cTns)
Is the biomarker of choice for the detection of myocardial injury
Cardiac troponins (cTns)
- Cardiac contusion
- Cardiac procedures (surgery, ablation, pacing, stenting)
- Acute or chronic CHF
- Aortic dissection
- Aortic valve disease
- Hypertrophic cardiomyopathy
- Arrhythmias (tachy- or bradyarrhythmia)
- Apical ballooning syndrome
- Rhabdomyolysis with cardiac injury
- Pulmonary hypertension
- Pulmonary embolism
- Acute neurologic disease (e.g., stroke, subarachnoid hemorrhage)
- Myocardial infiltrative diseases (amyloid, sarcoid, hemochromatosis, scleroderma)
- Inflammatory cardiac diseases (myocarditis, endocarditis, pericarditis)
- Drug toxicity
- Respiratory failure
- Sepsis
- Burns
- Extreme exertion (e.g., endurance athletes)
Conditions Associated With Elevated Cardiac Troponin Levels in the Absence of Ischemic Heart Disease (Table 48-5 page 333)
TRUE or FALSE?
In renal failure patients, elevation in cTnI is more common.
FALSE
cTn isoforms I & T provide nearly identical information except in the setting of renal failure, where elevation in cTnT (15% to 50%) is more common than cTnI(<10%).
TRUE or FALSE?
After dialysis, serum levels of cTnI generally increase, whereas cTnT levels decrease.
FALSE
After dialysis, serum levels of cTnT generally increase, whereas cTnI levels decrease.
cTnT = increase cTnI = decrease
TRUE or FALSE?
SN of two high-sensitivity cTn samples drawn within 3 hours of presentation approaches 100% for AMI.
TRUE
SN of two high-sensitivity cTn samples drawn within 3 hours of presentation approaches 100% for AMI.
AMI may safely be excluded with a single cTn in select, LOW-RISK patients with constant symptoms for —?— hours
> 6 to 12 hours
