Chest Pain and A.fib TBL Flashcards
How is the wells clinical prediction for pulmonary embolism interpreted?
Greater than six points: high-risk 2 to 6 points: moderate risk
less than two points: low risk
What is responsible for 40% of ER chest pain visits?
Musculoskeletal conditions and chest wall pain
List the top 3 causes of chest pain in primary care setting in order
Chest wall pain, reflux esophagitis, costochondritis
What are the four best independent predictors of musculoskeletal (versus cardiac or pulmonary) chest pain?
Absence of cough, stinging pain, pain that is reproducible on palpation, localized muscle tension
Which electrocardiogram findings can be used to predict acute MI?
ST elevation, new left bundle branch block, Q waves, hyperacute T waves
List key predictors of acute MI in patients with nearly normal ECG findings
Male sex,
older than 60,
pressure type pain,
pain radiating to arm, shoulder, neck or jaw
What five factors are used to predict patients whose chest pain is caused by CAD?
Age 55 or older in men, 65 or older in women Known CAD or CVD Pain not reproducible by palpation Pain worse during exercise Patient assumes pain is cardiogenic
How is risk calculated in clinical decision rule for determining chest pain caused by CAD?
Each variable worth 1 point
0 to 1 points: low risk
2 to 3 points: moderate risk
4 to 5 points: high-risk
What should you do for a patient with chest pain with low risk of MI?
Evaluate for non-cardiac causes
What should you do for a patient with chest pain at moderate risk for MI?
Order ECG to look for findings consistent with ischemic heart disease, and if positive give oxygen aspirin and transport to emergency department
What should you do for a patient with chest pain at high risk for MI?
Order ECG, give oxygen and aspirin and transport to emergency department
What should be done if moderate risk chest pain patient has normal ECG or nonspecific ST waves?
Order troponin testing, get eval by cardiologist and stress testing
What four components of an ECG indicate MI?
ST segment changes, new onset left bundle branch block, presence of Q waves, and new onset T-wave inversions
What should the initial approach to patient with chest pain be?
Always consider a cardiac etiology first
How does the presence of comorbidities (like diabetes, smoking, hyperlipidemia, hypertension) affect prediction of ACS in patients older than 40?
They are only weak predictors but should be included in initial assessment
Which seven factors are used to predict pulmonary embolism?
Clinical symptoms of DVT, other diagnoses less likely, tachycardia, immobilization within the past four weeks, previous DVT or PE, hemoptysis, malignancy
State the clinical triad of pericarditis
Pleuritic chest pain, pericardial friction rub, diffuse ECG ST T-wave changes
What is the best predictor of heart failure in clinical setting?
History of heart failure or acute MI
most present with dyspnea on exertion
Which three symptoms are present in 97% of those diagnosed with PE?
Dyspnea, tachycardia, and chest pain
Which symptoms are common in Thoracic aortic dissection?
Pain radiating to back, pulse differential in upper extremities
What is the CHADS method of identifying patients at increased risk of stroke?
Congestive heart failure, hypertension, age over 75, diabetes mellitus, previous stroke
Which patients is adjusted-dose warfarin recommended for?
All patients with non-valvular a fib who are at high risk of stroke and for some who are at moderate risk
Which patients is antiplatelet therapy with aspirin recommended for?
Patients with a fib at low risk of stroke and for some patients at moderate risk
What medication should be given to high-risk stroke patients with a fib and contraindications to anticoagulants?
Dual antiplatelet therapy with Plavix (clopidogrel) and aspirin
What therapy should be given to patients with history of ischemic stroke to have a fib?
Vitamin K antagonists
What combination of medicine carries a similar hemorrhagic risk to warfarin and should therefore be avoided in patients with history of stroke?
Clopidogrel and aspirin
When is dabigatran prescribed?
Patients with a fib and risk factors for stroke or systemic embolization who do not have a prosthetic heart valve, renal failure, or liver disease
When is Rivaroxaban prescribed?
To prevent strokes in patients with a fib though no AHA recommendations exist
What are two major problems with dabigatran, Rivaroxaban, and apixaban?
They have short half-lives, so patients who do not comply and missed doses may be at risk of thromboembolism
There are no antidotes to the drugs in cases of hemorrhage
Which four antithrombotics are approved for prevention of first and recurrent stroke in patients with a fib?
Warfarin, apixaban, rivaroxaban, and dabigatran
How is dosing determined for dabigatran?
Dabigatran-150 mg twice a day (or 75 mg twice a day if severe renal impairment-creatinine clearance of 15 to 30 mL per minute)
How is dosing determined for Apixaban?
Apixaban – 5 mg twice a day (or 2.5 mg twice a day if patient has two or more of the following characteristics: 80 or older, 133 pounds or less, serum creatinine of 1.5 or greater)
How is dosing determined for Rivaroxaban?
For patients with nonvalvular a fib at moderate to high risk of stroke, give 20 mg per day (or 15 mg per day if renal impairment-creatinine clearance of 15-50 mL per minute)
Do not use if creatinine clearance is less than 15 mL per minute
Is it more important to control rate or rhythm in a fib patients?
Rate control is preferred but rhythm control is an option for patients whose rate control cannot be achieved or who have symptoms despite rate control
What additional treatment is needed in addition to rate and rhythm control to prevent stroke?
Anticoagulation therapy (warfarin preferred over aspirin and clopidogrel)
What is the current recommendation for rate control and a fib patients?
Rate of less than 80 bpm
What are two surgical options for a fib treatment?
Disruption of abnormal conduction pathways in atria and obliteration of left atrial appendage
What two mechanisms are associated with triggering and maintaining a fib?
Enhanced automaticity in depolarizing foci, and reentry involving one or more aberrant circuits
What does chronic remodeling seen in a fib lead to?
Irreversible atrial enlargement
Which type of a fib carries the highest risk of stroke?
Valvular a fib caused by structural changes in mitral valve or congenital heart disease
Which a fib has the best prognosis and typically occurs in patients younger than 60 with no identifiable cause?
Lone a fib
What are the most commonly reported symptoms of a fib?
Palpitations, dyspnea, fatigue, lightheadedness, chest pain
What is used to diagnose a fib if ECG is nonspecific?
Holter monitor or cardiac event monitor
What treatment should be given to patients who are unstable because of hypotension, ischemia, heart failure, or CV events?
Emergency electrical cardioversion
List the two drugs used to control rate in a fib patients and state which is first-line agent
Beta blockers (first-line agent) and calcium channel blockers
Why is digoxin no longer used for rate control in a fib?
It has little effect during exercise-slows ventricular rate mostly by enhancing vagal tone
When should someone with a fib initiate anticoagulation (warfarin) therapy?
Three weeks before and four weeks after cardioversion
List some medications commonly used for cardioversion
Ibutilide, Flecainide, dofetilide, sotalol, amiodarone
Which medication used for cardioversion is a non-iodinated safer derivative of amiodarone?
Dronedarone
Which cardioversion medications are preferred in patients with heart failure?
Amiodarone and dofetilide
Which cardioversion medications are preferred in patients with preserved left ventricular systolic function?
Flecainide and propafenone
What should the INR of a patient taking warfarin be?
2–3
At what INR does the risk of stroke double?
1.8
Who are at higher risk of thromboembolic events, men or women?
Women
What CHADS score merits warfarin treatment?
2 or greater (moderate and high risk patients)
What treatment should patients with a zero or one CHADS risk score undergo?
Aspirin 81 to 325 mg per day
What factors are included to assess outpatient bleeding risk index in patients taking warfarin?
Older than 65, history of stroke, history of G.I. bleed, and one or more of the following: recent MI, severe anemia, diabetes, or renal impairment (each is one point)
Where do the majority of thrombi form?
In the left atrial appendage
When should an a fib patient be referred to cardiology?
Complex cardiac disease,
remains symptomatic on pharmacologic rate control, potential candidates for ablation or surgical treatment,
when they require a pacemaker or defibrillator
