Chest Pain Flashcards
Radiation to back; unequal BP between arms
Aortic dissection
Chest wall tenderness
Costochondritis
Chest pain worse with lying flat, better when sitting up; young pt < 40
Pericarditis
Epigastric discomfort; pain better with eating
Duodenal ulcer disease
Bad taste, cough, hoarseness
GERD
Cough, sputum, hemoptysis
Pneumonia
Sudden-onset SOB, tachycardia, hypoxia
Pulmonary embolus
Sharp, pleuritic pain; tracheal deviation
Pneumothorax
What is the best initial test for chest pain?
EKG
When do you take cardiac enzymes?
In the ED, after doing an EKG, for acute chest pain.
Never do cardiac enzymes in an office/ambulatory setting or when the chest pain is chronic or stable.
What is the most accurate test for costochondritis?
Physical examination
What is the most accurate test for aortic dissection?
Chest x-ray with widened mediastinum, chest CT, MRI, or TEE confirms the diagnosis
What is the most accurate test for pericarditis?
EKG with ST elevation everywhere and PR depression
What is the most accurate test for pneumonia?
Chest x-ray
What is the most accurate test for pulmonary embolus?
Spiral CT; V/Q scan
What is the most accurate test for pneumothorax?
Chest x-ray
Fever with chest pain suggests which 2 diseases as possible causes?
Fever suggests PE or pneumonia as the cause of chest pain.
What symptom in the setting of chest pain has the worst prognosis?
Shortness of breath
When do you do stress testing?
When the etiology of chest pain is unclear is uncertain and the EKG is not diagnostic. It requires that you can read the EKG and that the pt can exercise.
When is stress testing C/I?
If the pt is currently having chest pain.
What are some of the causes of EKG abnormalities that make the EKG unreadable?
Reasons for baseline EKG abnormalities include:
- LBBB
- LVH
- Pacemaker use
- Digoxin
What are 2 ways to detect ischemia if you cannot read an EKG?
- Nuclear isotope uptake using thallium or sestamibi; decreased uptake indicates dead or hypoperfused myocardium
- Echocardiographic detection of wall motion abnormalities; decreased wall motion during contraction indicates abnormal myocardium
How can you detect ischemia if the pt cannot exercise?
Alternate methods of increasing myocardial oxygen consumption are:
- Persantine (dipyridamole) or adenosine in combination with the use of nuclear isotopes such as thallium or sestamibi
- Dobutamine in combination with the use of echocardiography; dobutamine will increase myocardial oxygen consumption and provoke ischemia detected as wall motion abnormalities on an echocardiogram
What is the most accurate method of detecting CAD?
Angiography is used to detect the anatomical location of CAD. It is used to detect the presence of narrowing that is best managed with surgery, angioplasty, or other methods of revascularization.
What percent stenosis must a vessel be before clinically significant?
Stenosis of less than 50% of the diameter is insignificant. Surgically correctable disease generally begins with at least 70% stenosis.
Which medications (3) will lower mortality in chronic angina?
- Aspirin
- B-blockers
- Nitroglycerin
What is a Holter monitor used for?
Holter monitoring mainly detects rhythm disorders (eg atrial fib or flutter, ectopy such as premature beats, or ventricular tachycardia).
Holter monitor does not detect ischemia and is not accurate for evaluating the ST segment.
How is nitroglycerin delivered in chronic angina? How is it delivered in acute coronary syndromes?
NG can be delivered orally or by transdermal patch in chronic angina.
For acute coronary syndromes, NG is delivered in sublingual, paste, and IV form.
When is clopidogrel used?
- Aspirin intolerance such as allergy
- Recent angioplasty with stenting
For what 2 conditions are ACEI’s/ARB’s the DOC?
- Low EF / systolic dysfunction
- Regurgitant valvular disease
For what 4 diseases, equivalent to CAD, should the goal of LDL be below 100, and for which statins should be used to bring down the LDL if above 100.
- Peripheral artery disease (PAD)
- Carotid disease (not stroke)
- Aortic disease (the artery, not valve)
- Diabetes mellitus
Wide splitting of S2 with a loud P2 or tricuspid and pulmonary valve insufficiency; dyspnea; syncope
Pulmonary HTN
