Chest Pain Flashcards
Describe the phases of the cardiac cycle.
Starts in diastole (non-contracted) with cardiac chamber filling, systole begins with the S1 sound of the atrioventricular valves closing, the blood rushes through the open pulmonary and aortic valves and the heart contracts. As the contraction finishes the aortic and pulmonary valves close making the S2 sound and starting diastole once more.
What factors effect cardiac output?
CO = Heart Rate x Stroke Volume
The factors that effect HR:
- Autonomic system
- Hormones
- Fitness
- Age
The factors that effect SV:
- Heart size
- Fitness
- Sex
- Contractility
- Preload (increases)
- Afterload (decreases)
Features of cardiac originating chest pain?
Non-pleuritic, retrosternal, radiating, crushing pressure, triggered by activity, associated SOB and diaphoresis/ GI symptoms
What do S3 and S4 heart sounds indicate?
S3: ventricular gallop - the sound of blood hitting an overly compliant ventricle during passive filling. Cardiac myopathy. Can be a normal in young adults and children. Occurs just after S2.
S4: atrial gallop - the sound blood striking a non-compliant ventricle. Cardiac hypertrophy. Occurs just before S1.
Describe the murmur produced by mitral stenosis.
Low pitched, rumbling, best heard at the apex of the heart, diastolic, decrescendo-crescendo
Describe the murmur produced by mitral regurgitation
Pan-systolic, at apex, in lateral decubitus, high-pitched or blowing.
Describe the murmur produced by aortic stenosis.
Mid-systolic, high-pitched, best heard at pulmonic valve location, may radiate throughout, especially bilaterally to the carotids, crescendo-decrescendo
Describe the murmur produced by aortic regurgitation
Decrescendo, blowing, diastolic, at pulmonic valve location.
Pulmonary findings in CHF?
May find orthopnea, PND, SOB
This can be secondary to fluid back-up into the lungs, most prominent in left sided heart
CXR:
Kerley lines - interstitial edema
- Fuzzy full hilum, basal congestion - Pleural effusions
Bilateral fluffy infiltrates, alveolar- pulmonary edema
Name testing options for cardiac pathology
ECG Holter/Telemetry Echocardiogram (stress is an option too) Exercise/ Persantine stress test (MIBI MUGA Angiogram
What are the risks of an angiogram?
Bleeding, MI, arrhythmia, stroke, allergic reaction to dye
What anatomical mechanism causes wheezing?
Inspiratory wheeze - obstruction of the airways (very concerning)
Expiratory wheeze - premature collapsing airway
Tx for DVT/PE?
Give DOAC or LMWH bridge to warfarin for 3-6 months, need to check the kidney function for DOAC.
Critical steps for treatment of ACS?
Morphine - for pain control
O2 - if less than 88
Nitro - need to make sure not right sided, not on cAMP inhibitors, pressures ok
Aspirin - 325mg dose
Beta blocker - for less heart strain ACE - long term Statin - long term Heparin Clopidogrel
If can be done in less than 90 minute PCI, if more than that consider tPA - (no hemorrhagic stroke, no active malignancy intercranial, no ishemic in 3 months, no significant head trauma, no active aortic bleed/ major bleed) ideally BP controlled,
Chest pain DDx?
Bullet approach: Imagine a bullet passing through the chest, as it hits each structure think of the pathologies
Skin, muscle, bone/cartilage, lungs, heart, vessels, esophagus, spine
Cardiac risk factors
Age, smoking, sex, diabetes, Fhx, dyslipidemia, HTN, previous cardiac HI, certain cardiotoxic medications, obesity, ethnicity, inflammatory disorders
What should be done to screen for ACS
Monitor BP/ vitals , Hx for red flags, ECG, trops, Tele/monitor, consider bedside US, CXR.
What increases cardiac demand
Exercise, stress, pain, cardiomyopathy/ damage.
How might women present with MI?
Fatigue, lightheadedness, GI symptoms, arm pain
Becks triad?
Cardiac tamponade - muffled heart sounds, hypotension, distended neck veins
ST elevation in ECG leads and effected artery for anterior MI
Elevation in V1-4, LCA/LAD
ST elevation in ECG leads and artery for inferior MI
II, III, AVF - RCA
ST elevation on ECG leads and artery for lateral?
I, aVL, V5-V6, circumflex
ST elevation on ECG leads and artery for posterior MI
V7-V9 - look for reciprocal depression in the anterior leads
No nitro in MI if?
Right sided (Inferior) because the supply to the heart is pre-load dependant
Contraindications to tPA?
Active bleeding, malignancy, stroke in last 3 months, trauma, aneurysm or previous inter-cranial hemorrhage
Short PR interval?
WPW - delta waves - look for these as well - this is the most common. Risk of arrhythmia
First degree heart block - PR interval?
Lengthened. But still sinus. Be careful with CCB and BB
PR interval normal length?
0.12-0.20
QRS interval normal?
Between 0.08 and 0.10
Types of wide complex QRS?
Anything from the ventricle - 3rd degree heart block, VTach, PVC, hyperkalemia (imagine pulling on the baseline in two directions), pacemaker - look for a p-wave this helps eliminate any of the ventricle rhythm.
QT interval - corrected
From the start of the Q wave to the end of T, compare to RR interval - should be less than half of the RR - need to have a normal HR to do this.
Q waves?
Signs of old ischemia
What is normal QTc
400-450 ms - age and gender dependant - get worried around 500
What prolongs QT
Low Ca, Mg, K, anti-psychotics, methadone, SSRIs (some), TCAs, macrolide - azithromycin, fluoroquinolone, ondansatron, metoclopromide
Signs of ischemia
Peaked t’s, ST depression or elevation, Q-waves, LBBB, dynamic ECG, inverted Ts
RBBB ECG signs?
MORROW
V1 V6
With discordant T (opposite direction from the majority of the QRS.
LBBB ECG
WILLIAM
V1. V6
With discordant T waves
LBBB but also a MI?
Sgarbossa criteria
Wellen’s criteria
Test for ischemia - deeply inverted T wave in V3/4, biphasic T waves - sign of critical proximal LAD occlusion
Multifocal Atrial Tachycardia on ECG
Irregularly irregular - wandering SA node, Multifocal Atrial Tachycardia- seen in COPD - correct the COPD do not need to anti-coagulate
When do you need an anticoagulant for AF
If rhythm is persistent - over 48 hours need it
Angina - will there be elevated trops?
Nope.
Sx with the highest LR for cardiac chest pain?
Radiation of pain to both arms
Main initial goal in controlling a.fib?
Control ventricular rate - can use CCB, beta blockers
Then worry about anticoagulation
And if unstable consider cardioversion
How much time does the little square on the ECG represent?
0.04 secs
Approach to ECG interpretation
Rate Rhythm Axis Intervals Segments Ischemic Hypertrophy Conduction
ECG findings in PE?
Most commonly - sinus tachycardia or a.fib/flutter
Classic - S1Q3T3 ( S wave in lead 1 and a Q wave and inverted T in lead 3)
