Chest pain Flashcards
What medication do you want to give to control BP in aortic dissection and in what sequence do you want to give it?
- B-blocker (Esmolol) until HR <60 bpm
2. CCB (Nicardipine) to decrease BP <120/80
What medication do you want to avoid in cocaine induced chest pain?
beta blockers
T/F: Negative D-dimer rules out aortic dissection
True
What is the “triad” for aortic dissection?
- abrupt tearing chest pain
- pulse deficit >20 mmHg
- widened mediastinum
What is the criteria for a STEMI?
ST elevation of at least 1 mm in 2 contiguous leads (2mm in V2 and V3)
What is Beck’s triad and what is it pathognomonic for?
- Cardiac tamponade
- hypotension
- distended neck veins
- muffled heart sounds
What is the mainstay of treatment for an acute inferior wall MI while awaiting the cath lab?
- IV fluids!!
What area and artery is involved with STE in leads V1-V3?
- septal
- LAD
If you see a STEMI what should you do?
activate the cath lab!
doesn’t matter if troponin is negative
What area and artery is involved with STE in leads I, aVL, V4-V6?
- lateral
- Left circumflex artery (LCA)
37-year-old female with no significant past medical history presenting with acute onset chest pain and shortness of breath after having an argument with a co-worker. She describes her chest pain as a tightness across her chest, radiating into left arm, with associated shortness of breath and tingling in her fingertips and lips. On exam you notice hair loss, tremor and exophthalmos. What do you want to do next?
- Check if TSH is elevated
- Order 24-hour urine for pheochromocytoma
- Order toxicology screen
- Check if TSH is low
- It is just an anxiety attack
- Check if TSH is low
* hyperthyroidism leads to low TSH*
In what 3 populations does ACS have an atypical presentation?
- elderly
- women
- diabetics
what is the gold standard diagnostic imaging test for pericardial effusion?
echocardiogram
A patient presents with subcutaneous emphysema and mediastinal crackling with heart auscultation (Hamman’s sign). What is the diagnoses?
Boerhaave’s syndrome
Chest pain or epigastric pain, burning sensation, that worsens with food, NSAID use, at night or after lying down is consistent with what diagnosis?
GERD
Why do we use heparin as our primary anticoagulant in ACS?
it is short acting and patient is likely to undergo a procedure
A 26 yo female patient otherwise healthy presents with chest pain after a workout session. ECG, CXR, labs are fine. The pain is reproducible with palpation. What is the diagnosis?
musculoskeletal chest pain
What is pulsus paradoxus?
Change in SBP by at least 10 mmHg with inspiration caused by drop in stroke volume
A patient who recently recovered from covid-19 presents with sharp pleuritic chest pain that is worse with cough, laying down, and improved with sitting forward. On auscultation you hear a pericardial friction rub. ECG demonstrates diffuse ST elevations. What is the diagnoses?
pericarditis
If you suspect myocarditis/myopericarditis what imaging study to you want to get to confirm?
cardiac MRI
Infarctions are more commonly missed in these 3 populations?
- non white
- women <55
- patients with SOB as presenting symptom
How is myopericarditis/myocarditis treated?
- avoid NSAIDs, alcohol, and exercise
- begin heart failure therapy
A patient presents with ACS but has taken a baby aspirin, can he still receive a full dose?
yes 325mg!
What is the diagnostic criteria for myopericarditis?
- diagnoses of pericarditis PLUS
- e/o of myocardial damage (elevated troponin)
exclude other causes of elevated troponin
What area and artery is involved with STE in leads II, III, aVF?
- inferior
- right coronary artery
What is the best imaging study to diagnose aortic dissection?
Chest and abdomen CTA
even if a patient has poor kidney function
What classification system should we use for aortic dissection and what is it composed of?
- Stanford
- Type A: involves ascending aorta
- Type B: all other dissections
How is Boerhaave’s syndrome diagnosed?
- CXR
2. (if you see air) Chest CT I+/O-
In a high sensitivity troponin which of the following is more concerning?
- 5 to 10
- 20 to 16
- 45 to 50
- 9 to 24
- 6 to 6
- 9 to 24
- change is what we care about*
- it is sensitive not specific*
Why do you need to assess for pulsus paradoxus in cardiac tamponade?
cardiologists will argue that it is not cardiac tamponade unless patient is hypotensive and pulsus paradoxus is predictive of deterioration
Sudden, severe, sharp, tearing chest pain radiating to the back with bilateral blood pressure discrepancy of >20 mmHg and a diastolic decrescendo murmur is consistent with what diagnosis?
aortic dissection
What are the ECG changes in MI and what QRS changes coincide with each?
- early acute = hyperacute T waves
- acute = STE
- early subacute = Q waves and TWI begin
- late subacute = Q waves formed, full TWI
- chronic = Q waves present, T-wave return to upright
What is the difference in management of a STEMI vs NSTEMI?
- STEMI = cath lab immediately
- NSTEMI = cardiac consult for consideration of delayed cardiac cath
What are the 5 risk factors for pericardial effusion?
- pericarditis
- autoimmune dz
- trauma
- malignancy
- renal failure
T/F: Giving oxygen does not improve outcomes in patients with ACS unless they are hypoxic.
True
Why do patients with inferior wall MI typically present with a low/normal HR?
inferior MI can involve SA node/AV node
What is the most common life threatening emergency with chest pain?
ACS
What is the Sgarbossa criteria used for?
evaluating for a STEMI if LBBB present (regardless if new or old)
Low voltage and electrical alternans are ECG changes seen in what diagnosis?
pericardial effusion
What 2 lifestyle modifications have been shown to have the greatest improvement in GERD?
- weight loss
- head elevation
What is Wellen’s syndrome?
deeply inverted T waves in precordial leads, that are secondary to critical LAD stenosis
What is the acute treatment for cardiac tamponade?
What is the definitive treatment?
- acute treatment = increase preload with IV fluids
- definitive treatment = would be a pericardiocentesis (if emergency) or pericardiectomy (for stable patients)*
What area and artery is involved with ST depression in leads V1-V3 ?
- posterior
- right posterior descending artery
22-year-old male with no significant past medical history presenting with constant chest pain for 6 hours. He was at a party with friends and reports gradually worsening pain that he describes as chest pressure, non-radiating, with associated shortness of breath and diaphoresis. No fevers, cough, vomiting, numbness, tingling. What should always be on your differential?
cocaine
What is Boerhaave’s syndrome?
- full thickness tear of the esophagus leading to gastric contents leaking into mediastinum
- can lead to sepsis*
How is pericarditis treated?
- High dose NSAIDs (800mg Ibuprofen)
- if contraindication to NSAIDs = colchicine
patient needs to have activity restriction for 3 months
What layer of the aorta is dissected in an aortic dissection?
intima
What area and artery is involved with STE in leads V1-V6?
- anterior
- LAD
If you see a suspected inferior wall MI on an ECG what is the next thing you should do?
- Order morphine, oxygen, nitroglycerin, and aspirin, and activate the cath lab!
- Order full dose aspirin, heparin, nitroglycerin, activate the cath lab!
- Order a right sided EKG and activate the cath lab!
- Order a posterior EKG and activate the cath lab!
- Order a right sided EKG and activate the cath lab!
* need to see if the RV is involved before providing vasodilators*
What is the earliest EKG change in a STEMI?
Hyperacute T waves
What is the GI cocktail for treatment of GERD?
- Lidocaine PO, Maalox, H2 blocker
What are the 7 risk factors of ACS?
- hypertension
- hypercholesterolemia
- smoking
- diabetes
- family history of early CAD
- age over 50
- males/postmenopausal females
What are the 4 criteria for diagnosing pericarditis?
you only need 2/4 to diagnose
- typical history
- pericardial friction rub
- EKG changes
- pericardial effusion
How is the HEART score used to dictate management of patients with chest pain?
- score 0-3 = discharge
- score 4-6 = admit to the hospital
- score >7 = candidates for early invasive measures
What is the first line medication for pain management in ACS?
- nitroglycerin
* if contraindicated = morphine acceptable
Hyperventilation from an anxiety attack results in what metabolic abnormalities?
- low phosphorus
- low calcium
look for Chovstek’s sign
What are the 6 life threatening emergencies that should be on your differential for chest pain?
- ACS
- PE
- tamponade
- pneumothorax
- aortic syndromes
- esophageal rupture
How is an acute anxiety/panic attack diagnosed?
diagnosis of exclusion
How is Boerhaave’s syndrome acutely managed?
- NPO
- IVF and broad-spectrum IV antibiotics
- IV PPI (Omeprazole)
need to consult thoracic surgery and admit to surgical ICU
What is the change in management for aortic dissection if he has a Stanford type A vs. B dissection?
- Type A = surgical emergency
- Type B = medically managed by vascular
Right atrial _________ collapse and right ventricle _________ collapse are typical sonographic findings of cardiac tamponade.
- right atrial systolic collapse
- right ventricular diastolic collapse
What are the 3 contraindications for nitroglycerin to treat ACS?
- patient was on PDE5 inhibitor in last 24 hr
- hypotensive
- inferior wall MI
If a patient with a PMHx of Marfan’s syndrome presents with chest pain what is the diagnosis you should think about?
aortic dissection
What is the HEART score composed of?
- History
- ECG
- Age
- Risk Factors
- Troponin
