Chest pain

Question 1

What are some ddx for chest pain?

Answer 1

Anxiety
Aortic stenosis
Pericarditis
Pleuritis
Myocarditis
Cardiomyopathy
Aortic dissection
Asthma
Esophagitis
Gastroenteritis
MI
PE
Cardiac tamponade
HTN emergency 
Skin- lac or shingles

Question 2

What is the flow chart for Acute coronary syndrome?

Answer 2

1. Non cardiac
2. Stable angina
3. Unstable angina
4. Definite ischemic event

Question 3

What is the classic presentation of MI?

Answer 3

Pt presents early AM with substernal achy pressure

• Radiated pain to ant neck, shoulder, left arm, back and jaw
• 50% only have chest pain
• SOB
• Nausea
• Sweating

Question 4

What are some classic risk factors for MI?

Answer 4

Past hx of CAD

• Smoking
• HTN
• Hypercholesterolemia
• DMD
• Family hx of CAD
• Elevated CRP

Question 5

At what ages is family hx relevant?

Answer 5

Father

Question 6

Do women and young present with typical or atypical sx’s?

Answer 6

No they do not

• No pain
• SOB
• sweaty
• Syncope
• Palpitation
• indigestion
• weakness

Question 7

What does a new murmur suggest with a pt with chest pain?

Answer 7

MI which caused a papillary muscle rupture

Question 8

What looks the same about in EKG as NSTEMI?

Answer 8

Unstable angina

Question 9

Do most STEMI’s have q waves or no?

Answer 9

Most do

• Not definitive to rule it a STEMI if Q waves present though
• STEMI’s can also show up without Q waves

Question 10

What are some characteristics of stable angina?

Answer 10

Can be very frequent
Not always predictive of CAD in women (only 50-60%)
- Men 80-99% predictive

Question 11

What is Prinzmentals angina?

Answer 11

Vasospasm

• Ass with ST elevations
• Occurs at rest and often at night
• Rarely during exercise

Question 12

What is unstable angina?

Answer 12

Increases in duration, freq and intensity

• New ass sx’s
• Occurring with increasingly less activity at rest

Question 13

What is Grade I angina?

Answer 13

Ordinary physical activity does not cause angina such as walking or climbing stairs but very strenuous rapid or prolong exertion can evoke it

Question 14

What is grade IV angina?

Answer 14

Inability to carry our any physical activity

- angina at rest

Question 15

Criteria for defining an MI?

Answer 15

Elevated trop and at least 1 of the following:

1. Sx of ischemia
2. Q wave dev
3. New ST/T wave changes or new LBBB
4. Intracornary thrombus
5. Loss of cardiac wall (echo)

Question 16

Can EKG’s be normal with an MI?

Answer 16

yes nearly 1/3 early on

• get serial and compare. If not acute changes no reason for further evaluation
• If inferior get right side leads

Question 17

What is unique about a Posterior MI?

Answer 17

ST depression rather than elevation

Question 18

What is the dx criteria for STEMI?

Answer 18

STE >1mm in 2 contiguous leads

- if V2/3 need additional 2 contiguous lead with >2mm in men and >1.5 mm in women

Question 19

What is indicative of LBB on EKG with relation to T wave and QRS?

Answer 19

Discordant

- One goes up and the other goes down or vice versa

Question 20

What is indicative or diagnostic for MI regarding QRS and T wave?

Answer 20

Concordant
- Ones goes up and so does the other in just 1 lead
- > or equal too >1mm of Concordant STE
≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression

Question 21

What can cause a false + trop/

Answer 21

A-fib
Sepsis
Chronic kidney dz
- Can still be normal with unstable angina

Question 22

What heart scores and risk of MACE and their correlation to management?

Answer 22

0-3= 1-6% MACE: discharge them
4-6= 13% MACE: Admit for observation and serial trops and EKGs
7-10= 50% MACE: invasive intervention

Question 23

What is the management of possible ACS?

Answer 23

• Low risk: ASA, conservative observation with repeat troponin in 6-12 hours
• Moderate to high: nitroglycerin, heparin, repeat troponin in 6-12 hours
• Possibly repeat EKG before the repeat troponin.

Question 24

What is the management of a UA or NSTEMI?

Answer 24

PCI

Meds

Question 25

What is the management of STEMI?

Answer 25

Fibrinolytics
PCI with dilation and stinting
CABG
Meds like Heparin, aspirin and Ticegralor

Question 26

What are the antiplatelet management meds for MI besides aspirin?

Answer 26

• Clopidogel should be given if unable to take aspirin. Use in all patient less than 75 of age with UA/NSTEMI or STEMI
• Inhibits adenosine 5’-diphosphate (ADP)–dependent activation of the glycoprotein IIb/IIIa complex, a necessary step for platelet aggregation.
• Others: prasugrel, ticagrelor

Question 27

What are some anticoagulant therapies for MI?

Answer 27

-UFH (unfractionated heparin)
-Enoxaparin (low molecular weight heparin)
-Fondaparinux
similar to Enoxaparin
-Bivalirudin
direct thrombin inhibitors

Question 28

What are the glycoprotein IIb/IIIa inhibitors for?

Answer 28

• Use is primarily in conjunction with PCI
• Inhibit the integrin GP IIb/IIIa receptor in platelet membrane
• Inhibits final common pathway to activation of platelet aggregation

Question 29

Management in first 24 hrs for MI?

Answer 29

-Angiotensin converting enzyme inhibitors
in patients with CHF or LV ejection ≤ to 40% with no hypotension. If contraindicated use a angiotensin receptor blocker
-ß Blockers
an 11% reduction in mortality (use within 24 hours and not in high risk patients, low output , CHF, heart blocks, asthma) If contraindicated, use Calcium channel blockers (if no LV dysfunction)