Chest Pain Flashcards
6 life threatening causes of CP
ACS PE Aortic dissection Esophageal rupture Tension pneumothorax Pericardial tamponade
Common non-life threatening
gastrointestinal pulmonary (pneumonia or pleurisy) chest wall syndromes (musculoskeletal pain) psychiatric shingles
the main trifecta of
a. Myocardial Infarction (cardiac ischemia)
b. Pulmonary Embolism
c. Aortic Dissection
exertion related pain that is consistent
Angina! (CAD)
i went out yesterday i usually walk three block before experiencing some discomfort
If fully occlude –>you’ve had a STEMI
main and other RF for Angina and CAD
males greater than 45 women >55 trasnfats and cholesterol family DM HTN Smoking
a. Stress, depression, insomnia
b. Amphetamine/cocaine use
c. ESRD
d. Connective tissue disease (SLE, RA)
e. Vasculitis
f. HIV/HAART medications
g. Trauma
h. Any condition where O2 demand exceeds supply (GI bleed, sepsis)
for stable angina, how do you target with questions
ask about pain
what were you doing yesterday and last week and last year
need to get a progressive HX of sxs
unstable angina differs from stable
class III or class IV
at leas than two blocks or one flight of stairs
significant atherosclerosis
keep for stress test or send to cardiology
when ruling out ACS what are you ruling out exactly
want to rule out a STEMI and NSTEMI
three patterns of STEMI
- ST Depressions
- T wave inversions
- Wellens’ pattern
Definition of a NSTEMI
troponin increase in the absence of strict ECG criteria
2 Different causes for NSTEMI
2/3rds of the time supply/demand mismatches
can have this occur in sepsis with troponin release
can also be severely anemic and not have adequate oxygen delivery
1/3 occurs with occlusive myocardial infarction
NSTEMI tx
balloon, stent, thrombolitic
cardiogenic shock
hypotension and hypoprofusion associated with MI
due to MI or in the setting of cardiac dysfunction resulting form smaller events
AMI RF
EVERYONE
if you suspect MI get a troponin
common sxs with MI
CP does not radiate to legs but will radiate to back neck jaw shoulder and arms
sudden onset
can also see with dyspnea syncope nausea vomitting extreme weakness diaphoresis
ATYPICAL sxs of MI seen in this population
Women,
diabetics (b/c of neuropathy and visceral nerves have been dulled)
elderly, barriers to communication
(language, dementia, altered mental status/psych)
atypical sxs of MI
N/V cold sweats SOB fatigue syncope cold and clammy back pain palpitations
what two medications can not be used to rule in or rule out cardiac related CP
NTG–> will relieve non related CP
GI cocktail–> will relieve MI
current STEMI standard criteria
any ST segment elevation of over 1mm in all leads other than V2 or V3
how to
II,III,AVF
I and AVL (lateral)
v1,v2,v3,v4 depression
inferior wall MI
all pts coming in with CP with suspicion of MI
i. IV – 2 large PIVs
ii. O2 – Nasal Cannula (could be harmful)
iii. Cardiac monitor – HR/rhythm + BP
iv. At least 2 sets of EKGs/biomarkers
b. STEMI Treatment
i. Cath lab as soon as possible
ii. Balloon angioplasty or stent
iii. May need bypass surgery if severe or multi-vessel disease
iv. Thrombolytics only if delay in transferring to STEMI center
NSTEMI/Unstable Angina Treatment
Aspirin - 162mg, NON-enteric coated, chewable
1.Mortality benefit
2.4-5% mortality benefit
Additional anti-platelet agents (e.g. clopidogrel/plavix preferred)
LMWH
small benefit
Nitroglycerin
1. Except in hypotension/R sided MI/recent phosphodiesterase use
analgesia-opiates
once admitted
- High dose statin (Atorvastatin)
- Beta blockers (after 24 hours) – don’t give in acute phase
`3.ACE Inhibitors (when stable)
VI. Disposition
when would you give BB
Not acute–> associated with cardiogenic shock
initially just plavex and ASA send to cath lab
maybe second day
AD high risk conditions
Marfans syndrome
connective tissue disease
family history of aortic disease
known aortic valve disease
recent aortic manipulation
high risk pain features of AD
chest, back or abdominal pain described as the followingL abrupt in onset, severe in intensity and ripping/tearing or sharp quality
High risk exam features for AD
evidence of a perfusion deficit (pulse deficit, systolic BP differential, focal neurologic deficit- in conjunction with pain )
murmur of aortic insufficiency
hypotension or shock state
what is the CM of AD
sharp,
knife like
ripping or tearing pain
syncope
on exam a pulse deficit
new diastolic murmur
focal neurological deficit
hypotension that may be related to cardiac tamponade, aortic valve regurgitation, acute myocardial infarction
whta type of focal neurological deficit would you expect to see in pt with AD
stroke, ALOC, horner syndrome, haorseness, acute paraplegia from spinal cord ischemia
most common population with AD
HTN (80%)
▪ most important
predisposing factor
MC Age 50-60y
AD diagnostics
CXR
▪ widening of mediastinum (classic)
MRI Angiography → Gold standard
CT with contrast
▪ becoming test of choice
Transesophageal echo
ADD-RS plus D-dimer
(low risk with neg D-dimer–> you’re good)
either one high might need a negative D dimer
management of AD
ED management is lowering the HR and BP
HR<60 SBP 100-120
opiates for pain control
Surgical management
▪ Ascending or
▪ Descending with complications
Medical management
▪ Descending if no complications
- B-blockers 1st line: Esmolol, Labetolol
