Chest Discomfort Flashcards
When a patient presents to the ED what are the top five things on your differential (things you DO NOT want to miss)?
- ACS (exertional, retrosternal, may radiate to arm, jaw, neck, dull, diffuse)
- Pulmonary embolus (SOB, pleuritic, sharp)
- Aortic dissection (tearing, radiates to back, neurological symptoms)
- GI (GERD or spasm similar to ACS, but with acid taste and improvement with nitro or antacids)
- Tension pneumothorax (SOB, sharp, pleuritic)
- Pericarditis (sharp, pleuritic, positional, recent viral illness)
*PE, pneumothorax and dissection are unlikely but you don’t want to miss them!
Describe the pathology of ACS from 4 hrs to 2 months post damage.
Pathology of ACS
4-12 hrs = edema, hemorrhage
12-72 hrs = neutrophils, contraction band necrosis
3-7 days= necrosis of neutrophils, macrophage removal of dead cells at border
10-34 days = granulation with type I collagen
Describe the classes of the CCS guidelines.
Class I: Angina with strenuous or rapid or prolonged exertion at work or recreation.
Class II: Angina with walking more than two blocks and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.
Class III: Limitation of ordinary physical activity, angina with walking less than two blocks or 1 flight of stairs.
Class IV: Inability to carry on any physical activity without discomfort, angina at rest.
A 58 yr old male presents to hospital with a 3 day history of exertional, retrosternal chest pain, relieved with rest. This pain has become progressively worse and he now has pain at rest. The patient has a history of HTN but is otherwise healthy. His only medication is irbesartan 75 mg od.
PE: HR 80, BP 110/65, RR 16, O296%
JVP 2 cm above sternal angle, S1 normal, S2 physiologically split
No murmurs or extra heart sounds and the lung fields are unremarkable.
Why do you think this patient has unstable angina vs. stable angina?
Unstable angina is clinically defined by any of the following:
- Accelerating pattern of pain: increased frequency, increased duration, decreased threshold of exertion, decreased response to trtmnt
- Angina at rest
- New-onset angina
- Angina post-MI or post procedure (ex. PCI or CABG)
This guy has an accelerating pattern of pain.
A 58 yr old male presents to hospital with a 3 day history of exertional, retrosternal chest pain, relieved with rest. This pain has become progressively worse and he now has pain at rest. The patient has a history of HTN but is otherwise healthy. His only medication is irbesartan 75 mg od.
PE: HR 80, BP 110/65, RR 16, O296%
JVP 2 cm above sternal angle, S1 normal, S2 physiologically split
No murmurs or extra heart sounds and the lung fields are unremarkable.
What is the management for this patient?
All patients with ACS need admission to hospital.
Therapy: Oxygen ASA Clopidogrel Nitrates (if still having chest discomfort) Heparin or fondaparinux Beta-blockers Ace-Inhibitors (within 24 hrs) Statins
What is the definition of an MI?
MI is defined by evidence of myocardial necrosis. It is diagnosed by a rise/fall of serum markers plus any one of:
- Symptoms of ischemia (chest/upper extremity/mandibular/epigastric discomfort/dyspnea)
- ECG changes (ST-T changes, new BBB or pathological Q waves)
- Imaging evidence (myocardial loss of viability, wall motion abnormality, or intracoronary thrombus)
What investigations would you initially order with a presentation of chest discomfort?
CBC Electrolytes Creatinine Troponin CXR ECG
What is the treatment for acute pericarditis?
- Treat the underlying cause
- High dose NSAIDs/ASA, and Colchicine
What is the triad of acute pericarditis?
Acute pericarditis
- Chest pain
- Friction rub
- ECG changes: initially diffuse ST segments +/- elevated ST segments +/- depressed PR segment, elevation in the ST segment is concave upwards
What is the triad of cardiac tamponade?
Cardiac Tamponade
Beck’s Triad = Hypotension, Increased JVP, Muffled heart sounds
Also note that tamponade may elicit pulsus paradoxus, and hepatic congestion/peripheral edema.
