Chest Pain

Question 1

Common causes of nonemergent chest pain

in order from highest prevalence to least

Answer 1

1. Musculoskeletal (costochondritis)
2. GI, other/unknown
3. Cardiac (stable angina, other, then unstable/MI)
4. psychiatric
5. pulmonary

Question 2

S/S of GERD (non cardiac cause of chest pain)

Answer 2

visceral, substernal, worse w/ recumbency, no radiation, relief w/ food and antacids
-pain lasts 5 mins- 1 hr

Question 3

S/S of Esophageal spasm (non cardiac cause of chest pain)

Answer 3

• visceral, spontaneous, substernal, associated w/ cold liquids, relief w/ nitroglycerine
• pain lasts 5 mins- 1 hr

Question 4

S/S of Peptic ulcer (non cardiac cause of chest pain)

Answer 4

• visceral, burning, epigastric, relief w/ food and antacids, normal EKG
• pain lasts hrs

Question 5

S/S of Biliary disease (non cardiac cause of chest pain)

Answer 5

• visceral, epigastric, interscapular colic, occurs after meals
• pain lasts hours

Question 6

S/S of Cervical disc (non cardiac cause of chest pain)

Answer 6

-superficial, positional, arm and neck

Question 7

S/S of Musculoskeletal (non cardiac cause of chest pain)

Answer 7

-superficial, positional, worse w/ movement, local tenderness

Question 8

S/S of Hyperventilation (non cardiac cause of chest pain)

Answer 8

• visceral, substernal, tachypneic, anxious

- pain lasts 2-3 mins

Question 9

S/S of Thyroiditis (non cardiac cause of chest pain)

Answer 9

• aggravated by swallowing, neck, throat tenderness

- persistent

Question 10

TRUE chest pain (angina)

Answer 10

• Usually last 5-20 minutes
• Located retrosternal, left precordial
• Commonly referred to lower jaw, left arm
• Pressure, tightness, squeezing, “elephant sitting on my chest”
• Not sharp

Question 11

Definite angina

Answer 11

substernal discomfort precipitated by exertion, w a typical radiation to the shoulder, jaw or inner aspect of arm, relieved by rest or nitro in less than 10 mins

Question 12

Probable angina

Answer 12

Has most of the features of definite angina but my not be entirely typical in some aspects

Question 13

“Probably not” angina

Answer 13

atypical overall pattern of chest pain that does not fin in the description of definite angina

Question 14

“Definitely not” angina

Answer 14

chest pain is unrelated to activity, appears to be clearly of non-cardiac origin and is not relieved by nitro

Question 15

Associated symptoms with chest pain

Answer 15

Shortness of breath
Nausea
Diaphoresis
Palpitations
“Impending sense of doom”

Question 16

“Silent” MIs are most commonly seen in

Answer 16

elderly, women, diabetics

Question 17

TIMI risk score

Answer 17

-categorizes a patient’s risk of death and ischemic events and provides a basis for therapeutic decision making

Question 18

Calculating TIMI risk score

Answer 18

1 point for each:

• Age ≥ 65
• Aspirin use in the last 7 days (patient experiences chest pain despite ASA use in past 7 days)
• At least 2 angina episodes within the last 24hrs
• ST changes of at least 0.5mm in contiguous leads
• Elevated serum cardiac biomarkers
• Known Coronary Artery Disease (CAD) (coronary stenosis ≥ 50%)
• At least 3 risk factors for CAD:
  1. Hypertension -> 140/90 or on anti-hypertensives
  2. Current cigarette smoker
  3. Low HDL cholesterol (

Question 19

TIMI scoring

Answer 19

Score of 0-1 = 4.7% risk
Score of 2 = 8.3% risk
Score of 3 = 13.2% risk
Score of 4 = 19.9% risk
Score of 5 = 26.2% risk
Score of 6-7 = at least 40.9% risk

Question 20

Initial work up for chest pain

Answer 20

EKG
Cardiac enzymes
CXR

Question 21

OMM

Answer 21

rib raising