Chest Pain

Question 1

Six causes of life-threatening chest pain:

Answer 1

1. Acute MI/coronary syndrome
2. Pulmonary embolism
3. Aortic embolism
4. Tension pneumothorax
5. Pericardial tamponade
6. Esophageal rupture

Question 2

Leading cause of death in the US

Answer 2

Acute coronary syndrome (ACS)

Any condition brought on by a sudden reduction or blockage of blood flow to the heart.

Question 3

Define angina pectoris (stable)

Answer 3

Discomfort induced by exercise and relieved with rest or nitroglycerin

Question 4

Define unstable angina

Answer 4

More frequent, longer episodes, more easily provoked

Question 5

Define atypical or prinzmetal angina

Answer 5

Angina that occurs at rest

Question 6

Four high risk ssx for ACS

Answer 6

1. Pressure/squeezing
2. Pain similar to prior AMI/angina
3. Radiation to neck, shoulders or left arm
4. Dyspnea

Question 7

What should be noted in the workup of ACS?

Answer 7

Evaluate hemodynamic status
Vital signs
Skin color

Question 8

What should you consider with bradycardia in the setting of chest pain?

Answer 8

Inferior MI

Medication induced bradycardia with supra-therapeutic level of AV node blocking medication

Question 9

The leading cause of death for both men and women worldwide

Answer 9

Ischemic heart disease

Question 10

Risk factors for ACS

Answer 10

1. Previous CV disease
2. Older age
3. Tobacco smoking
4. High LDL/triglycerides and low HDL
5. Diabetes
6. High BP
7. Lack of physical activity
8. Obesity
9. Chronic kidney disease
10. Alcohol/drug use

Question 11

Differentiating SSX for aortic dissection

Answer 11

Unequal pulses
Pain radiating to the back
New murmur of aortic insufficiency

Question 12

Differentiation SSX for cardiac tamponade

Answer 12

Beck’s triad:
Low BP
Distended neck veins
Distant, muffled heart sounds

Question 13

Differentiating SSX for pneumothorax

Answer 13

Decreased breath sounds

Question 14

ACS most frequently occurs as a consequence of one of what three conditions?

Answer 14

ST elevation MI (STEMI)
Non-ST elevation MI (Non-STEMI)
Unstable angina

Question 15

The pathophysiology behind ACS is primarily due to what?

Answer 15

Endothelial injury and plaque formation that usually ruptures at sites of greatest mechanical stress

Question 16

Although ACS is usually associated with coronary thrombosis, it can also be associated with what?

Answer 16

Use of cocaine and methamphetamine

Question 17

What are the most often used blood markers for MI?

Answer 17

Creatine kinase-MB (CK-MB) fraction and Troponin levels

Question 18

What is the immediate treatment for suspected acute MI?

Answer 18

Oxygen
Aspirin
Sublingual nitroglycerin

Question 19

How are most cases of MI with ST elevation treated?

Answer 19

Reperfusion therapy (percutaneous coronary intervention or thrombolytic drugs)

Question 20

Beside MI, what can also result in release of Troponin?

Answer 20

Carbon monoxide or cyanide poisoning due to hypoxic cardiotoxic effects
Right ventricular strain and ischemia from hypertension, embolism, or acute exacerbation of chronic obstructive pulmonary disease
COPD can be concurrent with MI

Question 21

With an MI, when is Troponin elevated? (early, middle or late)

Answer 21

Late

Question 22

What is the immediate treatment for acute coronary syndrome?

Answer 22

MONA - morphine, oxygen, nitroglycerin, aspirin

Question 23

What is the definition of aortic aneurysm?

Answer 23

A general term for any swelling of the aorta >1.5 times normal usually representing an underlying weakness in the wall

Question 24

What are the SSX of aortic aneurysm?

Answer 24

Discomfort (risk of rupture -> severe pain, hemorrhage, death)
Hoarse voice due to compression of left recurrent laryngeal nerve

Question 25

What is cardiac tamponade?

Answer 25

The buildup of fluid, usually urea, inside the pericardium.

Question 26

Beside Beck's triad, what are some other SSX of tamponade?

Answer 26

Pulsus paradoxus Tachycardia Dyspnea Decreasing level of consciousness

Question 27

When should pulmonary embolism be suspected?

Answer 27

In any patient who presents with chest pain that is usually, but not necessarily pleuritic or dyspnea not explained by evaluation

Question 28

What are the SSX of pulmonary embolism and why are they not very useful?

Answer 28

``` Dyspnea Pleuritic chest pain Cough Hemoptysis Not very useful because frequency is similar among pts w/ and w/o PE ```

Question 29

What is the gold standard for diagnosing pulmonary embolism?

Answer 29

Pulmonary angiography

Question 30

What test is useful with suspicion of DVT, PE, or DIC?

Answer 30

D-dimer

Question 31

What is the criteria for a Wells score (for relative risk | of pulmonary embolism)?

Answer 31

``` Clinical suspicion of DVT (3) Alt Dx less likely than PE (3) Tachycardia (HR>100) (1.5) Immob. > 3d / Surg. in last 4 wks (1.5) Hx of DVT/PE (1.5) Hemoptysis (1) Malignancy (tx w/in 6 mos) (1) >6 high risk, ```

Question 32

What condition is a medical emergency that can cause steadily worsening levels of arterial oxygen concentration and low BP that if not reversed by tx can cause death?

Answer 32

Pneumothorax

Question 33

What are the SSX of tension pneumothorax?

Answer 33

Chest pain Respiratory distress >HR Tachypnea Displacement of trachea away from affected side Quieter breath sounds on one side of the chest

Question 34

What condition may have chest pain with fever, cough, and dyspnea?

Answer 34

Pneumonia

Question 35

What condition is defined as a benign, painful, nonsuppurative localized swelling on the costosternal, sternoclavicular, or costochondral joints?

Answer 35

Tietze's syndrome