Chest Pain

Question 1

Gastroesophageal Reflux Disease

Answer 1

Identifier - Retrosternal chest pain described as squeezing or burning sensation which is associated with eating or onset within minutes to a few hours after lying down

Treatment
Losing weight
Avoiding alcohol, chocolate, citrus juice
Avoiding large meals and eating on time
Waiting 3 hours after a meal before lying down
Elevating the head of the bed by 8 inches
Antacids (Tums)
PPI (Omez, Nexium, Pantecta)- given before meals
Long term side effect: osteoporosis, gastric atrophy, vitamin deficiency
H2 receptor antagonists and H2 blocker therapy (Zantac, Rantac)
Prokinetic medications and reflux inhibitors

Question 2

Costochondritis

Answer 2

Identifier - Localized and reproducible chest wall tenderness on palpation commonly at the 2nd rib.
Treatment
Rest Should be advised.
Ice can also be used to decrease the pain.
Light Stretches can be undertaken to aid in dexterity of the anterior chest wall
Non-Steroidal Anti-Inflammatory ( NSAIDS) such as Ibuprofen or Naproxen should be used to aid in pain relief and to reduce inflammation of the costochondral junctions.
Topical Analgesia, such as diclofenac rubs, can be utilized.

Question 3

Stable Angina

Answer 3

Identifier - Crushing retrosternal chest pain on exertion which is relieved by rest or nitroglycerin
Treatment
Lifestyle Modifications:
Smoking cessation,
Modifying diet,
Regular exercise
Control and Management of pre-existing comorbid conditions such as diabetes and hypertension
Glyceryl Trinitrate (GTN) Sublingual(patch useless) for vasodilation and chest pain relief.
Prophylaxis ASA 81mg po od
Surgical intervention such as PCI or CABG

Question 4

Acute Coronary Syndrome

Answer 4

Identifier - Severe central crushing chest pain not relieved by rest with radiation to either arm or jaw
Treatment
Medical Management ( 1-3 symptom relief, 4-6 ACS protocol)
M – Morphine
O – O2 Therapy
N – Nitrates
A – Aspirin (Antiplatelet therapy)
ADP receptor inhibitors - clopidogrel
Anticoagulation - Low molecular weight heparin (clexane)
Beta blockers
ACE inhibitors
Statins (Atorvastatin)
Fibrinolysis
Surgical Management
PCI (coronary angioplasty ) – Gold Standard – done from 90 mins from door to balloon
Atherectomy – catheter placed up the femoral to the heart and the tip contains a rotating shaver to cut away the plaque from the artery.
CABG
Coronary Stenting

Question 5

Pulmonary Embolism

Answer 5

Identifier - Sudden onset dyspnea followed by central pleuritic chest pain with DVT risk factors (Surgery, Immobilization, recent hospitalization)

Treatment
Thrombolysis: rt-PA, alteplase
Anticoagulation - With LMWH for 5 days then start warfarin and discontinue LMWH when INR stabilizes between 2-3
Embolectomy
Vena Cava Filters
Compression stockings