Chest pain Flashcards
What are some ddx for chest pain?
Anxiety Aortic stenosis Pericarditis Pleuritis Myocarditis Cardiomyopathy Aortic dissection Asthma Esophagitis Gastroenteritis MI PE Cardiac tamponade HTN emergency Skin- lac or shingles
What is the flow chart for Acute coronary syndrome?
- Non cardiac
- Stable angina
- Unstable angina
- Definite ischemic event
What is the classic presentation of MI?
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
What are some classic risk factors for MI?
Past hx of CAD
- Smoking
- HTN
- Hypercholesterolemia
- DMD
- Family hx of CAD
- Elevated CRP
At what ages is family hx relevant?
Father
Do women and young present with typical or atypical sx’s?
No they do not
- No pain
- SOB
- sweaty
- Syncope
- Palpitation
- indigestion
- weakness
What does a new murmur suggest with a pt with chest pain?
MI which caused a papillary muscle rupture
What looks the same about in EKG as NSTEMI?
Unstable angina
Do most STEMI’s have q waves or no?
Most do
- Not definitive to rule it a STEMI if Q waves present though
- STEMI’s can also show up without Q waves
What are some characteristics of stable angina?
Can be very frequent
Not always predictive of CAD in women (only 50-60%)
- Men 80-99% predictive
What is Prinzmentals angina?
Vasospasm
- Ass with ST elevations
- Occurs at rest and often at night
- Rarely during exercise
What is unstable angina?
Increases in duration, freq and intensity
- New ass sx’s
- Occurring with increasingly less activity at rest
What is Grade I angina?
Ordinary physical activity does not cause angina such as walking or climbing stairs but very strenuous rapid or prolong exertion can evoke it
What is grade IV angina?
Inability to carry our any physical activity
- angina at rest
Criteria for defining an MI?
Elevated trop and at least 1 of the following:
- Sx of ischemia
- Q wave dev
- New ST/T wave changes or new LBBB
- Intracornary thrombus
- Loss of cardiac wall (echo)
Can EKG’s be normal with an MI?
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
What is unique about a Posterior MI?
ST depression rather than elevation
What is the dx criteria for STEMI?
STE >1mm in 2 contiguous leads
- if V2/3 need additional 2 contiguous lead with >2mm in men and >1.5 mm in women
What is indicative of LBB on EKG with relation to T wave and QRS?
Discordant
- One goes up and the other goes down or vice versa
What is indicative or diagnostic for MI regarding QRS and T wave?
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
What can cause a false + trop/
A-fib
Sepsis
Chronic kidney dz
- Can still be normal with unstable angina
What heart scores and risk of MACE and their correlation to management?
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
What is the management of possible ACS?
- 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.
What is the management of a UA or NSTEMI?
PCI
Meds
What is the management of STEMI?
Fibrinolytics
PCI with dilation and stinting
CABG
Meds like Heparin, aspirin and Ticegralor
What are the antiplatelet management meds for MI besides aspirin?
- 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
What are some anticoagulant therapies for MI?
-UFH (unfractionated heparin)
-Enoxaparin (low molecular weight heparin)
-Fondaparinux
similar to Enoxaparin
-Bivalirudin
direct thrombin inhibitors
What are the glycoprotein IIb/IIIa inhibitors for?
- 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
Management in first 24 hrs for MI?
-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)
