Chest pain Flashcards

1
Q

What are some ddx for chest pain?

A
Anxiety
Aortic stenosis
Pericarditis
Pleuritis
Myocarditis
Cardiomyopathy
Aortic dissection
Asthma
Esophagitis
Gastroenteritis
MI
PE
Cardiac tamponade
HTN emergency 
Skin- lac or shingles
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2
Q

What is the flow chart for Acute coronary syndrome?

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

What is the classic presentation of MI?

A

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
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4
Q

What are some classic risk factors for MI?

A

Past hx of CAD

  • Smoking
  • HTN
  • Hypercholesterolemia
  • DMD
  • Family hx of CAD
  • Elevated CRP
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5
Q

At what ages is family hx relevant?

A

Father

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6
Q

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

A

No they do not

  • No pain
  • SOB
  • sweaty
  • Syncope
  • Palpitation
  • indigestion
  • weakness
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7
Q

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

A

MI which caused a papillary muscle rupture

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8
Q

What looks the same about in EKG as NSTEMI?

A

Unstable angina

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9
Q

Do most STEMI’s have q waves or no?

A

Most do

  • Not definitive to rule it a STEMI if Q waves present though
  • STEMI’s can also show up without Q waves
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10
Q

What are some characteristics of stable angina?

A

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

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11
Q

What is Prinzmentals angina?

A

Vasospasm

  • Ass with ST elevations
  • Occurs at rest and often at night
  • Rarely during exercise
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12
Q

What is unstable angina?

A

Increases in duration, freq and intensity

  • New ass sx’s
  • Occurring with increasingly less activity at rest
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13
Q

What is Grade I angina?

A

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

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14
Q

What is grade IV angina?

A

Inability to carry our any physical activity

- angina at rest

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15
Q

Criteria for defining an MI?

A

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)
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16
Q

Can EKG’s be normal with an MI?

A

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
17
Q

What is unique about a Posterior MI?

A

ST depression rather than elevation

18
Q

What is the dx criteria for STEMI?

A

STE >1mm in 2 contiguous leads

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

19
Q

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

A

Discordant

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

20
Q

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

A

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

21
Q

What can cause a false + trop/

A

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

22
Q

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

A
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
23
Q

What is the management of possible ACS?

A
  • 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.
24
Q

What is the management of a UA or NSTEMI?

A

PCI

Meds

25
Q

What is the management of STEMI?

A

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

26
Q

What are the antiplatelet management meds for MI besides aspirin?

A
  • 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
27
Q

What are some anticoagulant therapies for MI?

A

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

28
Q

What are the glycoprotein IIb/IIIa inhibitors for?

A
  • 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
29
Q

Management in first 24 hrs for MI?

A

-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)