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CRRAB I Final > Chest Pain - Adams > Flashcards

Chest Pain - Adams Flashcards

1
Q

What usually happens with angina?

A

It’s hard to diagnose

-Go on to having MI fairly often in next 10 days!

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2
Q

What is the classic presentation of chest pain?

A
  • -Hx: pt presents in the early AM with substernal achy pressure pain radiates to anterior neck, shoulders, L arm, & back.
  • -~50% of patients will have “chest pain”
  • -Shortness of breath (dyspnea), nausea, sweating (diaphoresis)
  • -Risk factors: past hx of CAD, smoker (risk returns to normal 5 yrs after quitting), HTN, elevated cholesterol, diabetes, family hx of coronary DZ (father
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3
Q

What does a typical physical exam for chest pain look like?

A
  • Chest clear
  • CV: RRR without murmur, S3, S4 or rub
  • Abdomen: soft, guaiac negative stool (no blood in the stool)
  • Legs: no edema
  • Skin: diaphoretic (sweaty)
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4
Q

What are alternative presentations of chest pain?

A
  • Women, the young, and the old have inc. freq. of presenting with atypical symptoms
  • No “pain” just: SOB, sweaty, syncope, stroke, palpitation, indigestion, weakness
  • Adjectives: heartburn, indigestion, sharp, squeezing, burning, numbness
  • Location of pain may only be in referred areas, or be in atypical areas such as right arm/hand, or abdomen
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5
Q

What does an S3 sound mean?

A

Left ventricular dysfunction

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6
Q

What does an S4 sound mean?

A

Decreased left ventricular compliance (cannot occur in atrial fibrillation since it is caused by atrial contraction driving blood into ventricle and against an abnormal ventricular wall)

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7
Q

What does CHF present as with chest pain?

A

Crackles, hepatojugular reflex, leg edema

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8
Q

What do you need to know about UA vs. NSTEMI?

A

Unstable angina (UA)/non ST-elevation myocardial infarction (NSTEMI) - EKGs look same initially

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9
Q

What is angina?

A

A symptom rather than a diagnosis.

  • Mismatch of O2 demand and delivered O2 to cardiac muscle resulting in ischemia, which is reversible.
  • Symptom last
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10
Q

What is stable angina?

A
  • Can be very frequent and still be “stable”

- Typical angina is less predictive of CAD in women (probability is 50 to 60% in women versus 80-99% in men)

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11
Q

What is prinzmetal’s angina?

A

Vasospasm, associated with ST elevations

-Occurs at rest, often at night, rarely with exercise

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12
Q

What is unstable angina?

A

(10% will have an MI in 7 days)

  • Increasing duration, frequency, or intensity; new associated symptoms
  • Occurring with increasing less activity or at rest
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13
Q

What is Angina Grade I?

A

“Ordinary physical activity does not cause angina,” such as walking or climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.

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14
Q

What is Angina Grade II?

A

“Slight limitation of ordinary activity.” Angina occurs on walking or climbing stairs rapidly; walking uphill; walking or stair climbing after meals; in cold, in wind, or under emotional stress; or only during the few hours after awakening. Angina occurs on walking more than 2 blocks on the level and climbing more than 1 flight of ordinary stairs at a normal pace and under normal conditions.

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15
Q

What is angina Grade III?

A
  • “Marked limitations of ordinary physical activity.” Angina occurs on walking
  • 1 to 2 blocks on the level and climbing 1 flight of stairs under normal conditions and at a normal pace.
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16
Q

What is angina Grade IV?

A

“Inability to carry on any physical activity without discomfort—anginal symptoms may be present at rest.”

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17
Q

What two things must you have for an MI?

A

Elevation of troponin and at least one of the following:

  • Sx of ischemia
  • Q wave development
  • New ST/T wave changes or new LBBB
  • Intracoronary thrombus (angiogram or autopsy)
  • Loss of cardiac wall (ECHO)
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18
Q

What do you see on EKG of MI?

A
  • Initially normal in 1/3 of MIs
  • If EKG abnormal, yet not obvious MI, compare to prior EKG
  • -If there are no acute changes, there is no reason to evaluate the patient based on the abnormal EKG
  • If inferior MI, get right side leads EKG looking for right ventricle infarct
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19
Q

What do you see on EKG with STEM?

A
  • ST elevation >0.1 mV (one box) on all leads but V2 & V3 >/= 0.2 mV (2 boxes)
  • New LBBB (difficult to diagnose ST elevation because LBBB have ST elevation normally)
  • Posterior MI unique –> “back of the heart” infarct –> ST elevation will appear as ST depressions
20
Q

What do you see on EKG with NSTEMI?

A
  • Horizontal or downward sloping ST depression >/= 0.05 mV in 2 contiguous leads
  • T wave inversion >/= 0.1 mV with prominent R wave or R/S ratio > 1 in 2 contiguous leads
21
Q

What does troponin tell you?

A
  • Pos. up to 2 weeks after MI, Low sensitivity early in MI (50% + at 3 hrs)
  • If normal at 6 hours, AMI can be excluded unless very high risk then get a 12 hour also
  • False + in anything that stresses the heart = afib, sepsis, chronic kidney disease
22
Q

What is HIGH sensitivity troponin?

A
  • More rapidly positive
  • Higher sensitivity at the price of lower specificity
  • Can send someone home if you get a one time negative value or sequential test 2-3 hours apart
  • How does time of onset of pain vs. time of arrival to ED affect sensitivity
  • Can still be normal with unstable angina!
23
Q

CPK-MB?

A

It and its ratio with total CPK is no longer used routinely since it does not add to diagnostic accuracy

24
Q

CRP?

A

There is an increase in mortality if it is elevated but its diagnostic or predictive value is still not clear

25
Q

What can you find with ECHO (ultrasound) in chest pain?

A
  • Specifically: if you perform an ECHO on a patient who is having ongoing chest pain and you find no wall motion abnormality, there is a low probably of the chest pain be cardiac origin.
  • Prior heart disease can show as wall motion abnormality so ECHO is not very useful if wall motion abnormality is seen
  • If pt with chest pain has normal echo, you can rule out MI (can’t rule in though)
26
Q

What does management depend on?

A

Patients’ risk of having cardiac dz

27
Q

Little chance of cardiac dz:

A

Must have plausible diagnosis upon discharge

  • Normal EKG (or no change)
  • Consider cardia enzymes - especially if symptoms have been constant or peaked > 8 hrs ago
  • Document follow up
28
Q

Possible cardiac dz:

A

Let the history drive you

  • Use with caution:
  • -Normal EKG
  • -Nitro trials (under tongue tablets)
  • -Cocktails of lidocaine and antacid (10% of MI feel better with GI cocktail)
  • -Cardiac enzymes
  • Admit vs. discharge (with diagnosis, clear patient instructions, and early follow up)
29
Q

Management of possible ACS? Low risk

A
  • ASA (aspirin), conservative observation with repeat troponin (in 6-12 hours)
  • Moderate to high: nitroglycerin, heparin, repeat troponin in 6-12 hours
30
Q

Management of possible ACS? Moderate to high risk

A

Nitroglycerin, heparin, repeat thrombin in 6-12 hours

-Possibly repeat EKG before the repeat troponin

31
Q

What should you use to treat UA/NSTEMI?

A
  • PCI (percutaneous coronary intervention)

- Medications

32
Q

What should you use to treat STEMI?

A

(STE elevations or new LBBB)

  • Fibrinolytics (tPA, reteplase) - only works for STEMI
  • PCI with dilation and stinting
  • CABG (Coronary Artery Bipass Graft (s))
  • Medications
33
Q

What should you use oxygen for?

A

Oxygen if hypoxic - may be harmful if patient is normoxic (keep O2 sat >/= 94%)

34
Q

What should nitroglycerin be used for?

A

If angina & selectively for MI (best place for nitro is CHF)
-Not for RV infarct which occurs in ~50% of inferior MIs - it reduces preload and caused BP to drop

35
Q

What should morphine be used for?

A

Pain unresponsive to nitroglycerin and is a stopgap. It can cause HTN.

36
Q

What is MONA?

A

Morphine, Oxygen, Nitro, Aspirin

  • Death - not really used anymore
  • Aspirin is the only one that should be used widely
37
Q

What Antiplatelets should be used early in chest pain?

A
  • Aspirin - HUGE IMPACT ON MORBIDITY AND MORTALITY IN PRESENCE OF ACUTE MI
  • Thienopyridines:
  • -Clopidogel should be given if unable to take ASA; use in all patients less than 75 of age with UA/NSTEMI or STEMI
38
Q

What is the MOA for Clopidogel?

A

Inhibits ADP-dependent activation of GPIIb/IIIa complex, a necessary step for platelet aggregation

39
Q

What anticoagulants should be used early in chest pain?

A
  • UFH (unfractionated heparin)
  • Enoxaparin (low mol weight heparin) - can’t make it go away very quickly, don’t use it if you’re going to the cath. lab
  • Fondaparinux = similar to Enoxaparin
  • Bivalirudin = direction thrombin inhibitors
40
Q

What Glycoprotein IIb/IIIa inhibitors should be used in early chest pain?

A
  • Use is primarily in conjunction with PCI
  • Inhibit the intern GPIIb/IIIa receptor in platelet membrane
  • Inhibits final common pathway to activation of platelet aggregation
  • Names: Abciximab, Eptifibatide, Tirofiban
41
Q

What two drugs should be used to reduce mortality in the first 24 hours?

A
  • Angiotensin converting enzyme inhibitors

- Beta blockers

42
Q

What are angiotensin converting enzyme inhibitors?

A
  • In patients with CHF or LV ejection = to 40% with no hypotension
  • If contraindicated use an angiotensin receptor blocker
43
Q

What are Beta blockers?

A
  • An 11% reduction in mortality (use within 24 hrs and not in high risk patients, low output, CHF, heart blocks, asthma)
  • If contraindicated, use Calcium channel blockers (if no LV dysfunction)
44
Q

What do you need to document with chest pain?

A

Character: radiation, duration
Associated symptoms: SOB, diaphoresis, N/V
PHx: HTN, DM, smoking, cholesterol, cardiac disease, FH
Exam: vital signs, CV, pulmonary

45
Q

KEY POINTS:

A
  • Offer other adjectives when eliciting a history
  • Not all patients present with “chest pain” as presenting symptom
  • Epigastric pain with no findings - consider cardiac ischemia
  • Get a lot of EKGs and repeat them!
  • ASA (Aspirin!)
  • EKGs and labs should not be used to decide if a patient is sent home

CRRAB I Final (21 decks)

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