CHAPTER 48: Chest Pain

Question 1

Is the recent onset of pain, pressure, or tightness in the anterior thorax between the xiphoid, suprasternal notch, and both midaxillary lines

Answer 1

Acute chest pain

Question 2

Approximately —?—% of patients with AMIs are not diagnosed on initial presentation to the ED

Answer 2

Approximately 2%

Question 3

Is defined by myocardial necrosis with elevation of cardiac biomarkers and is classified by ECG findings

Answer 3

Acute myocardial infarction (AMI)

Question 4

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

Answer 4

Unstable Angina (UA)

Question 5

Pain which is easily described, precisely located, and often experienced as a sharp sensation

Answer 5

Somatic pain

Somatic = S = Sakto

Question 6

Pain which is generally more difficult to describe and imprecisely localized

Answer 6

Visceral pain

Question 7

Pain more likely described as discomfort, heaviness, pressure, tightness, or aching

Answer 7

Visceral pain

Question 8

Initiate cardiac monitoring and IV access, and obtain an ECG, ideally within —?— minutes of arrival

Answer 8

within 10 minutes of arrival

Question 9

In patients complaining of chest pain, administer oxygen if ambient saturation is —?—%

Answer 9

<94%

Question 10

Is a feeling of retrosternal left anterior chest crushing, squeezing, tightness, or pressure

Answer 10

Classic cardiac chest pain

Question 11

The Multicenter Chest Pain Study reported that —?—% of patients with AMI described their chest pain as sharp or stabbing

Answer 11

22%

Question 12

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

Answer 12

Pre- & early menopausal women

Question 13

Nonclassic presentations of acute coronary syndrome occur more frequently in these patient groups

Answer 13

Women
Racial minorities
AMS
Psychiatric disease
Elderly
Diabetics

WRAPED

Question 14

Common associated symptom of chest pain in FEMALES

Answer 14

Nausea, Emesis, Jaw pain, Neck pain, & Back pain

Question 15

Common associated symptom of chest pain in MALES

Answer 15

Diaphoresis

Question 16

Raise suspicion for ACS in patients complaining of epigastric or upper abdominal discomfort, especially for patients —?— years old or those with known CAD

Answer 16

> 50 years old

Question 17

Age >40 y/o
Male or postmenopausal female
HTN
Tobacco use
Hypercholesterolemia
Diabetes
Truncal obesity
FMHx
Sedentary lifestyle

Answer 17

Major risk factors for CAD

Question 18

Is associated with AMI even in young people with minimal or no CAD

Answer 18

Cocaine use

Question 19

Are the historical features most strongly associated with ACS

Answer 19

Radiation to the arms and shoulders

Exertional chest pain

Question 20

TRUE or FALSE?

Lack of exertional pain or pain radiation has no diagnostic value for exclusion of ACS.

Answer 20

TRUE

Lack of exertional pain or pain radiation has no diagnostic value for exclusion of ACS.

Question 21

Physical examination findings most strongly associated with AMI in patients presenting with acute chest pain

Answer 21

Hypotension
S3 gallop
Diaphoresis

Question 22

Reproducible chest wall tenderness suggesting a musculoskeletal etiology, is reported in up to —?—% of patients with confirmed AMI

Answer 22

up to 15%

Question 23

Is the test of choice and is highly sensitive for the detection of large to medium-sized PEs

Answer 23

CT pulmonary angiography

Question 24

Pain from this condition is classically described as a ripping or tearing sensation radiating to the interscapular area of the back

Answer 24

Aortic dissection

Question 25

Patients classically present with a history of sudden-onset sharp substernal chest pain following forceful vomiting

Answer 25

Esophageal rupture (Boerhaave’s Syndrome)

Question 26

Audible crepitus that varies with the heartbeat on auscultation of the precordium, is a rare finding associated with pneumomediastinum

Answer 26

Hamman’s crunch

Question 27

Approximately —?—% of patients with a spontaneous pneumothorax may develop a tension pneumothorax

Answer 27

Approximately 1% to 3%

Question 28

Pain from this condition is classically described as a sharp, severe, constant pain with a substernal location

Answer 28

Acute Pericarditis

Question 29

Is the most specific physical exam finding in acute pericarditis but is not always evident

Answer 29

Pericardial friction rub

Question 30

Pain in this condition is characterized by sharp,highly localized, & positional pain

Answer 30

Musculoskeletal or chest wall

Question 31

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

Answer 31

Costochondritis (Tietze’s syndrome)

Question 32

Is an inflammation of the xiphoid process that causes sharp, pleuritic chest pain reproduced by light palpation

Answer 32

Xiphodynia

Question 33

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

Answer 33

Precordial catch syndrome (Texidor twinge)

Question 34

Is an inflammation of the parietal pleura resulting in sharp pleuritic chest pain

Answer 34

Pleurisy

Question 35

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

Answer 35

Gastritis & esophageal reflux

Question 36

Is classically described as a postprandial, dull, boring pain in the epigastric region; Patients often describe being awakened from sleep by discomfort.

Answer 36

Peptic ulcer disease (PUD)

Question 37

Pain relieved after eating food

Answer 37

Duodenal ulcer pain

Question 38

Pain exacerbated by eating

Answer 38

Gastric ulcer pain

Question 39

Typically present with right upper quadrant or epigastric pain and tenderness but can also cause chest pain

Answer 39

Acute pancreatitis & biliary disease

Question 40

Is often associated with reflux disease and is characterized by a sudden onset of dull or tight substernal chest pain

Answer 40

Esophageal spasm

Question 41

Pain frequently precipitated by consumption of hot or cold liquids or a large food bolus and may be relieved by nitroglycerin

Answer 41

Esophageal spasm

Question 42

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

Answer 42

Panic disorder

Question 43

About —?— % of the patients identified as having panic disorder were ultimately diagnosed with ACS

Answer 43

9%

Question 44

Is the imaging test commonly performed in the evaluation of ED patients with chest pain

Answer 44

Chest radiography

Question 45

Guidelines recommend a screening ECG within —?— minutes of ED arrival in patients with chest pain or other symptoms concerning for ACS

Answer 45

within 10 minutes

Question 46

TRUE or FALSE?

A normal ECG has the sensitivity to exclude ACS.

Answer 46

FALSE

A normal ECG lacks the sensitivity to exclude ACS, notably unstable angina or NSTEMI.

Question 47

Among young patients w/out known CAD, a normal ECG is assoc with a cardiovascular event rate of —?—% at 30 days

Answer 47

<1% at 30 days

Question 48

For high concern for ACS, the ECG should be repeated at —?—minute intervals and compared to prior ECGs

Answer 48

15 to 30-minute intervals

Question 49

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

Answer 49

Cardiac troponins (cTns)

Question 50

Is the biomarker of choice for the detection of myocardial injury

Answer 50

Cardiac troponins (cTns)

Question 51

• 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)

Answer 51

Conditions Associated With Elevated Cardiac Troponin Levels in the Absence of Ischemic Heart Disease (Table 48-5 page 333)

Question 52

TRUE or FALSE?

In renal failure patients, elevation in cTnI is more common.

Answer 52

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%).

Question 53

TRUE or FALSE?

After dialysis, serum levels of cTnI generally increase, whereas cTnT levels decrease.

Answer 53

FALSE
After dialysis, serum levels of cTnT generally increase, whereas cTnI levels decrease.

cTnT = increase
cTnI = decrease

Question 54

TRUE or FALSE?

SN of two high-sensitivity cTn samples drawn within 3 hours of presentation approaches 100% for AMI.

Answer 54

TRUE

SN of two high-sensitivity cTn samples drawn within 3 hours of presentation approaches 100% for AMI.

Question 55

AMI may safely be excluded with a single cTn in select, LOW-RISK patients with constant symptoms for —?— hours

Answer 55

> 6 to 12 hours