Chest Pain (7 questions) Flashcards
Common causes of ischemic CV pain
- ACS > NonSTEMI, unstable angina, STEMI
- Angina
Common causes of nonischemic CV chest pain
Systemic HTN, AV regurg, AS, arrhythmias, pericarditis, aortic dissection, MVP
Where may chest pain originate other than the heart?
Pulmonary, GI, Musculoskeletal, Psychogenic, Neuropathic…
Examples of pulmonary chest pain
PE, PHTN, pneumothorax, pleuritis, pneumonia
Causes of GI chest pain
GERD, esophageal rupture, PUD, esophageal spasm, pancreatitis, biliary dz
Causes of Musculoskeletal chest pain
costochondritis, Tietze syndrome, Rib fracture, cervical disc
Causes of psychogenic chest pain
panic do
causes of neuropathic chest pain
HZ
Describe common characteristics of ischemic chest pain
- typically deep pain: retrosternal or substernal and felt across both sides of the chest and down the medial aspect of the left arm
- described as: pressure, tightness, crushing, squeezing, aching
- Radiating below the diaphragm and above the mandible?? →Rarely ischemic
What would you see on an EKG for ischemic chest pain?
- may show
- ST elevation, depression (downsloping or horizontal appearing) or T wave inversions.
- Changes may not be present in some cases
Describe common characteristics of angina:
how, when, where, duration, assoc sx
- “Strangling of the chest”
- Transient episodes of sub-sternal CP
- Associated with exertion & emotional distress
- Especially with hurrying, walking on an incline, walking in cold or windy weather
- May be accompanied by:
- Arm, jaw, back, neck pain
- Nausea, vomiting. dyspnea, diaphoresis can occur
What relieves angina?
- Relieved with rest or NTG
Is angina located in the middle or lower abdominal region?
no
Can anginal pain be localized by one finger?
no
Is angina a constant pain that lasts many hours or fleeting pain that lasts a few seconds or less?
neither
Does anginal pain radiate to lower extremities?
no
What is vasospastic angina?
- Also called Printzmetal’s Angina or Variant Angina
- Pain similar to classic angina but onset at rest
conditions assoc w/vasospastic angina
- 25% also have migraines and Raynauds
- More common with heavy smokers
What testing may be done to confirm vasospastic angina?
- ST elevation on EKG
- Spasm provoking testing done during cardiac cath
- Mixed angina is possible-combination of classic and spastic; Atheromas may encourage spasm
What would be Rxed for vasospastic angina?
Ca channel blockers and nitrates may be indicated for spasm
What are “anginal equivalents”?
A symptom representing angina which is not chest pain/discomfort
- Nausea, vomiting, diaphoresis, DOE, or fatigue
- In diabetic or the elderly: fatigue, epigastric discomfort, DOE, palpitations, lightheadedness
- Dyspnea is the most common anginal equivalent
Common symtpoms of MI and unstable angina?
- CP: pressure, squeezing, fullness, aching burning, heaviness
- Radiation to the jaw, neck, arms, teeth
- With SOB, nausea, diaphoresis, lightheadedness
- Pain waxes and wanes, lasts more than 15 minutes
- USA pain may occur with little exertion or at rest
- Stable disease is now unstable
- Pain with decreased workloads is concerning
- Rest pain is very concerning and requires admission
What are some less typical Sx of ACS?
- Pain in area other than chest
- Numbness, tingling, stabbing, burning
- No chest pain
- Indigestion
- Lightheadedness
- Fatigue
Women: symptoms of ACS
nausea, lightheadedness, unusual fatigue, upper back pain
Elderly: sx of ACS
dyspnea, mild Sx, vague report, no CP
Diabetes: Sx of ACS
weakness, dyspnea, nausea, palpitations, no CP
What are some biomarkers of acute MI?
CK - total and MB
Troponin
Myoglobin
Lactate dehydrogenase
How long does troponin stay around?
up to 10 days
What is/ causes pericarditis?
- Inflammation of the pericardial sac
- Commonly caused by viral, bacterial or fungal infections, trauma, surgery, MI
- Also caused by neoplasms (breast and lung Ca and lymphoma- more commonly), radiation, uremia (RF), post cardiac surgery, autoimuune diseases, antiphospholipid syndrome
Pericarditis: gender and age groups
Incidence higher in males
Ages 20-50
Characteristics of the pain of pericarditis
- Pericarditis pain waxes and wanes over hours to days (can last 30 mins or more at a time)
- Pain: sharp, piercing, localized discomfort in the retrosternal area and left precordium radiating to the back and left shoulder
- CP exacerbated by deep inspiration, cough, lying down and improves when sitting up and leaning forward
Pericarditis Sx (in addition to pain)
Sx: Dyspnea, cough, chills, weakness
Fever may be present
What does / does not relieve the pain of pericarditis?
Pain occurs suddenly & is unrelieved with nitrates, relieved by sitting forward
NOT relieved by rest
When might pericarditis occur in relation to an MI?
- Can occur 2-4 days post MI
- Dressler’s syndrome can occur 3 weeks to several months post AMI (injury to heart muscle that causes blood in pericardium → pericarditis)
What medications can cause pericarditis / lupus like Syndrome?
pronestyl, cardizem, INH, apresoline. Collagen Diseases: SLE and RA can develop pericarditis
Findings associated with pericarditis
- ST segment elevation on EKG (diffuse-most leads except V1 and AVR)
- Physical Findings: pericardial friction rub (left lower sternal border 4-5 ICS)
Position patient: lean forward and exhale
- Jugular vein distends on inspiration when the patient is sitting at a 45 degree angle
Complications of pericarditis
Tamponade (hypotension, JVD, muffled heart sounds)
EKG changes associated with pericarditis over time
- Day 2-3 and up to 2 weeks: Diffuse ST elevation. PR seg. depression II, V4-6
- Days-several weeks: ST segment at baseline with flat T waves
- 2-3weeks-several weeks: T wave inversion
- Weeks-up to 3 months: Gradual resolution of T waves
Tests ordered in pericarditis
- CXR
- EKG
- Echocardiogram
- Labs
- ESR
- CBC
- LFTs
- PT/PTT
- CPK/Troponin
- Possibly: ANA, RF, TB screening, HIV
Sx of Pulmonary Embolus
- Sudden onset pleuritic CP, SOB, may have hypoxia
- Other symptoms: cough, hemoptysis (30%), dyspnea, or no symptoms at all
Risk factors for pulmonary embolus?
pelvic or leg trauma, neoplastic disease, travel, immobility, recent surgery, obesity, hypercoagulable states, oral contraception, cigarette smoking
Clinical manifestations of pulmonary embolus
- 60% of people have a HR >100, 85% have rapid respirations >20/min
- EKG: ST depression II, III, F, V2, V3, inverted T waves but there may be no changes
Tx for Pulmonary Embolus
anticoagulation
Diagnostic tools in PE
- CXR
- Compression venous U/S of the legs (Duplex Doppler Ultrasound)
- ECG
- ST and T wave changes 70% of pts
- ABGs
- D-Dimer test
- Measure of fibrin levels
- Sensitivity 85-100%
- Specificity 40-68%
- Ventilation/Perfusion Scan (V/Q scan) - MOST LIKELY or
- Helical Cat Scan (Spiral CAT Scan) - MOST LIKELY
- Pulmonary Angiography - GOLD STANDARD
Sx of aortic dissection
- Pain is usually persistent, severe, ripping, tearing, knife-like
- May be felt in the chest or back
- Pain may migrate following the path of dissection—Chest, back, flank
- Dissection pain is prolonged but stops when the dissection is complete
Risk factors for aortic dissection
history of HTN, Marfans syndrome, bicuspid aortic valve, atherosclerosis, aortic surgery, known aneurysm
What causes the pain of aortic dissection?
Pain is due to compression of the adjacent structures or vessels, or a thromboembolic event
Possible complication of aortic dissection
Myocardial ischemia/infarct can occur due to aortic compression by dissection or hematoma. The RCA is commonly involved
Testing done in suspected aortic dissection
CT scan, arteriogram, ultrasound
Tx aortic dissection
Emergency Surgery
Sx of pneumothorax
- Sudden onset of substernal pain located to right or left chest at rest (ipsilateral side)
- Radiates widely to right or left chest
- Pain in arms, shoulder, back
- Increases with deep inspiration
- Changes to dull, steady ache over time
- SOB at rest
- Tachycardia, tachypnea
Risks for pneumo
More common with COPD, cigarette smoker
Diagnostic tests for pneumo
CXR
Sx of MVP
intermittent sharp or tugging left sided CP without radiation
Other symptoms may include: fatigue, SOB, orthopnea, syncope, palpitations
MVP: relationship with exertion
none
Risks for MVP
Common in people who are lean, thin and may have skeletal abnormalities, i.e. Marfan syndrome, or pectus excavatum, scoliosis
more common in women
MVP: what you may find on PE
Midsystolic click at apex with mid-late systolic murmur-may be intermittent
Dx tests for MVP
echocardiogram
Endocarditis: causitive agents
1) S. Aureus
2) Strep Viridans
Endocarditis: risk factors
IV Drug Abusers, central lines, prior valve replacement/valvular surgery, recent dental surgery, weak valves
(more males, kids, elderly)
Sx of endocarditis
Fever, diaphoresis, chills, aches & pains; splinter hemorrhages
Diagnostic tests for endocarditis
- Blood cx
- CBC
- CRP
- ESR
- Urine
- EKG
- Echo
- TEE
Tx for endocarditis
- Long term IV antibiotics
- Supportive care
- Valvular repair
Secondary complications of endocarditis
- Thrombi
- CHF
- CVA/TIA
- Glomerulonephritis
What prophylaxis would be given for endocarditis before dental work?
Amoxicillin 2g 1 hr before procedure
Ampicillin, ceftriaxone for IV.
What 4 groups should receive prophylactic antibiotics?
- pts w/ prosthetic valves
- pts w prior IE
- cardiac transplant w valulopathy
- certain congenital HD
- includes shunts, conduits, w/I 6 months of cardiac transplant (post 6 months don’t need abx)
- Pts w MVP (w or w/o regurg) NO LONGER need prophy
What types of procedures warrant prophylactic antibiotics?
- If involve manipulation/perforation of oral mucosa
- Respiratory surgery involving incisions or biopsy of respiratory mucosa (tonsillectomy)
- DO NOT need for GI/GU procedure.
Sx of aortic stenosis
- Can range from Mild to Severe
- Substernal pain which may radiate to the jaw, arms, neck.
- Can have a dramatic presentation: syncope
What causes the pain associated with AS?
Ischemic pain!
Thickened heart muscle needs more O2 to pump, but decreased cardiac output so not getting it
Clinical signs of AS?
May have a systolic ejection murmur radiating to neck
Diagnostics for AS
- Diagnostics: Echocardiogram, cardiac cath
- Cardiology consult prior to any consideration of stress test (syncope)
Sx of GERD chest pain
- Substernal CP radiates to arms ,back, neck, jaw
- Pain occurs 20-30 minutes after meals
- Pain may last for several hours
- Exacerbated by lying down, nocturnal, bending
- Burning in throat or bad taste in mouth
What meds aggravate / alleviate GERD?
- Relieved with antacids, belching
- Worse with NTG or Ca channel blockers
Diagnostics for GERD
radiologic testing, endoscopy-EGD
(esophagogastroduodenoscopy)
Tx of GERD
antacids, PPI or H2 blockers
Sx of biliary dz
- Pain radiates to the chest, upper back, shoulder(s)
- Usually occurs after high fat meals
- May be accompanied by nausea and vomiting, fever
- May also have right upper quadrant pain which may be described as sharp pain
- Patient may be very uncomfortable during an acute episode
- Not related to exertion
*
Diagnostics for Biliary Dz
Labwork, U/S, HIDA scan may confirm GB disease
Risk factors for biliary dz
5 Fs- Fat, Fair, Female, Forty, Fertile
Sx of costochondritis/chest wall pain
- Superficial localized or pain at one or more of the costrochondral junctions, one or more of which may be tender to touch or with movement: Point tenderness; no swelling
- May have a sudden or gradual onset
- Worse with deep breath ; or movement of the shoulder girdle
- Common cause of CP for ages 10-21 yrs (up to 40)
- Occasionally find Tietze’s syndrome: + swelling, erythema or warmth at the junction
Tx of costochondritis/chest wall pain
NSAIDS, moist heat, rest
Sx of chest muscle spasm
- Sudden onset of sharp grabbing pain in the anterior chest, often on the left side
- Lasts < 3 minutes
- Resolves spontaneously
- May also intensify with breathing
Diagnostics for chest muscle spasm
history, PE
Characteristics of postcardiotomy pain
- Post chest surgery pain
- Chest pain, shoulders, upper back
- Increase with movement, palpation
- Sharp, fleeting nonexertional CP
- Zapping nerve like pain-particularly in right or left upper chest (LIMA, RIMA)
Questions to ask if suspect postcardiotomy pain
Determine date of surgery
Onset of pain-does it coincide with surgical intervention?
Diagnostics for postcardiotomy pain
PE
Sx of herpes zoster pain
- Sharp, stabbing pain on one side of the chest
- Pain prior to the vesicles up to 48 hours
- Herpetic vesicles along the dermatome
- Doesn’t cross the midline
Diagnostics for HZ
PE
Tx of HZ
Acyclovir, neurontin, pain medication
Sx of pleuritis
- Fairly localized stabbing, sharp, shooting pain
- Worsening pain with deep inspiration: pleuritis
- Concurrent or preceeded by: respiratory infection, pneumonia, pneumothorax, PE, malignancy, collagen disease
- Rub may be heard with lung auscultation
Tx pleuritis
Treat underlying cause, pain medication
Sx asthma
- Feeling of chest constriction
- Anxiety, cough, wheeze, poor air exchange
- Dypsnea
- Associated with infection, chemical triggers, allergies, stress
- Fam Hx of allergy/asthma/eczema; Aspirin allergy
Asthma tx/mgmt
Relieved by nebulized albuterol, steroids, antibiotics if indicated and other medication
Sx of pneumonia
- Pain may or may not be present
- Gradual onset
- May be referred to abdomen
- Fever
- Cough: may be non-productive at first
- Fatigue
- Adventitious breath sounds
Diagnostics for pneumonia
CXR, WBC count
Tx of pneumonia
Antibiotics-bacterial; otherwise supportive care
Cause of chest pain associated w/palpitations
- May result from ischemic and nonischemic process
- Patients can feel palpitations with any heart rhythm
- Sinus tachycardia increases MVO2 and can cause CP in those with CAD, AS, cardiomyopathy
Diagnostics fo palpitations
Holter, event monitor, EKG, echo, possible stress test
Rx for palpitations
maybe BBs
How do you make the dx of chest pain d/t panic d/o?
R/O other causes
Tx of CP d/t Panic Do
treatment for anxiety
What to do if CP of CV origin?
EKG, monitor
Remember MONA?
- Morphine
- Oxygen(2-4L NP nasal prongs?)
- Nitrates (none for AS)
- Aspirin (ASA 4-81mg or 1-325mg)
Nitrates and aortic stenosis
may cause severe hypotension in AS!
any drug that causes hypotension should be used with caution or not at all
