Chest pain Flashcards
Important DDx of chest pain
- Cardiac causes
- ACS: unstable angina, MI
- Angina
- Atypical or variant angina (coronary vasospasm, Prinzmetal)
- Cocaine-induced
- Pericarditis
- Aortic dissection
- Valvular heart disease (aortic stenosis, mitral valve prolapse)
- Non-ischemic cardiomyopathy
- Syndrome X - GI causes
- Esophageal disease (GERD, esophagitis, esophageal dysmotility)
- Biliary disease (cholecystitis, cholangitis)
- PUD
- Pancreatitis - Pulmonary disorders
- Pneumonia
- Spontaneous pneumothorax
- Pleurisy
- PE
- Pulmonary HTN/cor pulmonale - Musculoskeletal causes
- Chostochondritis
- Rib fracture
- Myofascial pain syndromes
- Muscular strain
- Herpes zoster - Psychogenic
- Panic disorder
- Hyperventilation
- Somatoform disorder
Factors that can exacerbate or provoke ischemic chest pain
- Increase myocardical oxygen demand
- Tachycardia or tachyarrhythmia
- HTN
- Increased wall stress (aortic stenosis, cardiomyopathy)
- Hyperthyroidism - Decreased myocardial oxygen supply
- Anemia
- Hypoxemia
RF for coronary heart disease
- Age
- Male gender
- FHx sudden death or premature CAD
- Personal Hx peripheral vascular or CVD
- Smoking
- Lipid abnormalities (dietary Hx of saturated fat and cholesterol)
- DM
- HTN
- Obesity
- Sedentary lifestyle
- Cocaine use
- Estrogen use
- Chronic inflammation
Critical Hx in chest pain
Characteristics of chest pain:
- location
- quality
- severity
- radiation
- duration
- context (exertional, postprandial, positional, coacine use, trauma)
- associated symptoms (sweating, nausea, dyspnea, palpitation, sense of doom)
- exacerbating/alleviating factors (esp medicaitons)
- Hx similar symptoms
- Known heart/lung disease or Hx of diagnostic testing
- Cardiac RF (HTN, HLD, smoking, FHx of early MI)
- PE RF (Hx of DVT, coagulopathy, malignancy, recent immobilization)
- Differentiate angina, atypical angina, and non-cardiac chest pain
- Characteristics of angina: substernal, precipitated by exertion, releived by rest or nitroglycerin - Other Hx
- RF of coronary heart disease
- Previous Hx of ischemic heart disease or valvular heart disease (RF, cardiac murmurs)
- Previous Hx of PVD or CVD
- Assess functional status
PE of chest pain
- BP: recogintion of BP findings in
- Aortic stenosis (low pulse pressure)
- Aortic insufficiency (high pulse pressure)
- Pulsus paradoxus - Pulses, bruits
- Neck veins for distension, abdominal jugular reflux
- Conjunctiva and optic fundus
- Extremties for skin condition, color, temp, presence of edema, xanthomas, cyanosis, clubbing
- Lungs for crackles, rhonchi, rubs, decreased breath sounds
- Inspection of chest for heaves, lifts, thrills
- Auscultation of heart for rhythm, intensity of heart sounds, splitting of S2, presence of rubs, gallops (S3, S4, summation) or extra heart sounds (e.g., clicks)
- Ausculatation for murmurs
- Timing (systolic vs diastolic; holosystolic vs ejection)
- Pitch, location, pattern of radiation
- Guage significance (innocent vs pathologic, sclerosis vs stenosis) - Abdomen for epigastric or RUQ tenderness, hepatomegaly, abnormal pulsations or bruits
Potential labs in chest pain
- Cardiac biomarkers
- 12-lead ECG
- CXR
- ABG
- Echo
- Exercise stress test
- Stress thallium (myocardial perfusion scan)
- Dobutamine stress echo
- Coronary angiography
- Electron beam CT scan (for coronary calcification)
- V/Q scan
- PE protocol CT scan
- Pulmonary angiography
Pt counseling in chest pain
- Dx, Px, Tx, f/u
- Age appropriate counseling on RF for CVD
- Smoking cessation
- Reduction in saturated fats and cholesterol
- Restriction in sodium
- Weight reduction
- Increased physical activity
60 M sudden onset substernal heavy chest pain, lasted 30 min, radiates to L arm, accompanied by dyspnea, diaphoresis, nausea, Hx of HTN, HLD, smoking
DDx
- MI
- GERD
- Angina
- Costochondritis
- Aortic dissection
- Pericarditis
- PE
- Pneumothorax
Workup
- ECG
- TroponinI and CK-MB x 3
- CXR
- CBC, electrolytes
- Echo
- Cardiac Cath
20 F, african american, acute onset chest pain for few hours, Hx sickle cell disease, multiple previous hospitalizations for pain and anemia management
DDx
- Sickle cell disease-pulmonary infarction
- Pneumonia
- PE
- MI
- Pneumothorax
- Aortic dissection
Workup
- CBC, reticulocyte count, LDH, peripheral smear
- ABG
- CXR
- CK-MB
- ECG
- CTA- chest with IV contrast
45 F retrosternal burning sensation occurs after heavy meals and when lying down, relieved by antacids
DDx
- GERD
- Esophagitis
- PUD
- Esophageal spasm
- MI
- Angina
Workup
- ECG
- Barium swallow
- Upper endoscopy
- Esophageal pH monitoring
55 M retrosternal squeezing pain lasts 2 minutes and occurs with exercise, relieved by rest, not related to food intake
DDx
- Angina
- Esophageal spasm
- Esophagitis
Workup
- ECG
- CK-MB
- CXR
- CBC, electrolytes
- Exercise stress test
- Upper endoscopy/pH monitor
- Cardiac catheterization
34 F retrosternal stabbing chest pain, improves when she leans forward, worsens with deep inspiration, had URI 1 wk ago
DDx
- Pericarditis
- Aortic dissection
- MI
- Costochondritis
- GERD
- Esophageal rupture
Workup
- ECG
- CK-MB, troponin-I
- CXR
- Echo
- CBC
- Upper endoscopy
34 F stabbing chest pain worsens with deep inspiration, relieved by aspirin, had URI 1 week ago, chest wall tenderness noted
DDx
- Chostochondritis
- PNA
- MI
- PE
- Pericarditis
- Muscle strain
Workup
- ECG
- CK-MB and troponin-I
- CXR
- CBC
70 F presents with acute onset SOB at rest and pleuritic chest pain, tachycardia, hypotension, tachypnea, mild fever, recovering from hip replacement
DDx
- PE
- PNA
- Costochondritis
- MI
- CHF
- Aortic dissection
Workup
- ECG
- CXR
- ABG
- CK-MB, troponin
- CBC, chem 7
- CTA-chest with IV contrast
- Doppler US legs
- D-dimer
55 M sudden onset severe chest pain radiates to back, Hx of uncontrolled HTN
DDX
- Aortic dissection
- MI
- Pericarditis
- Esophageal rupture
- Esophageal spasm
- GERD
- Pancreatitis
- Fat embolism
Workup
- ECG, CK-MB, troponin
- CXR
- CBC, amylase, lipase
- Transesophageal echocardiography, MRI/MRA aorta
- Aortic angiography
- Upper endoscopy
