Chest Pain Assessment

Question 1

What is CV patient assessment?

Answer 1

the evaluation of subjective and objective patient-specific data to enable:
• decisions regarding the health status of the patient, drug therapy needs, and problems (medical or drug-related),
• interventions to resolve drug therapy problems and prevent future drug therapy problems, and
• follow-up to ensure patient outcomes met

Question 2

Cardiac Assessment 4 Underlying Principles

Answer 2

• Anatomy
• Myocardial perfusion and vasculature competence
• Pump function
• Electrical conduction

Question 3

core signs and symptoms (acronym)

Answer 3

• Symptoms
• Characters
• History
• Onset
• Location
• Aggrevating
• Remitting
• Onset
• Provokers
• Quality
• Relievers
• Severity
• Timing
• Associated symptoms
• Pertinent negatives

Question 4

Chest pain: differential 4x rules

Answer 4

1. Not all cheat pain is related to the heart
2. Chest pain from the heart can be from a number of different etiologies
3. timeline of symptoms is important
4. change in symptoms over time is important

Question 5

How to categorize chest pain relevance

Answer 5

Patient: Can you help me pick out an antacid, I am having some heart burn (rubs chest)?

Pharmacist: Can you tell me a little about your symptoms?

From the symptoms: decide on 1. Self-limiting OTC suggestion, 2. Urgent: refer to MD 3. Emergency: refer to ED

Question 6

Evaluating Cardiac Chest Pain (CP) components:

Answer 6

• Quality
• Location
• Duration
• Associated symptoms
• Provokers
• Relievers

Question 7

Evaluating Cardiac Chest Pain (CP) quality:

Answer 7

• “squeezing”, “gripping”, “pressure”, “heavy”
• discomfort rather than pain
• not be tender to touch
• changing with position/inspiration may occur with
pericarditis

Question 8

Evaluating Cardiac Chest Pain (CP) location:

Answer 8

• substernal or retrostenal

* radiation: neck, jaw, epigastrium, back, arms

Question 9

Evaluating Cardiac Chest Pain (CP) duration:

Answer 9

• usually minutes (2-5 min), usually not more than 10 min

Question 10

Evaluating Cardiac Chest Pain (CP) associated symptoms:

Answer 10

• CNS: lightheaded, fatigue
• CVS: dyspnea, palpitations
• GI: nausea
• Ext: diaphoresis

Question 11

Evaluating Cardiac Chest Pain (CP) provokers: 4 E’s

Answer 11

• usually predictable

* 4Es: Exertion, Emotional distress, Extreme temperatures, Eating

Question 12

Evaluating Cardiac Chest Pain (CP) Relievers:

Answer 12

• rest or SL nitroglycerin (NTG)

Question 13

Clinical classification of CP - Cardiac vs possible cardiac vs non cardiac

Answer 13

Cardiac
1. substernal with characteristic quality and duration
2. provoked by exertion or emotional stress
3. relieved by rest or NTG
Possible cardiac
• 2 of the above
• More common in DM and elderly
Non cardiac
• 1 or none of the above
• Non-ischemic cardiac, pulmonary, GI, chest wall, psychiatric

Question 14

Canadian Cardiovascular Society (CCS) Classification of Angina (4 classes)

Answer 14

Class Description
I Ordinary physical activity does not cause angina, such as walking and climbing stairs. Occurs with strenuous, rapid or prolonged exertion at work or recreation
II Slight limitation of ordinary activity. Occurs on walking or climbing stairs rapidly, uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after wakening
III Marked limitations of ordinary physical activity. Occurs on walking 1-2 blocks level and climbing 1 flight of stairs in normal conditions at a normal pace (100-200m)
IV Inability to carry on any physical activity without discomfort. Anginal symptoms may be present at rest.

Question 15

Unstable Angina

Answer 15

Rest angina: Occurs at rest and usually prolonged >20 min
New onset angina: At least CCS III within 2 mos of presentation
Increasing angina: Previously diagnosed angina worsening over < 4 wks:
- more frequent
- longer in duration
- lower threshold

Question 16

Differentiating Chest Pain (Cardiac, GI, MSK)

Answer 16

Cardiac: History - Rick factors for CVD. Type of pain - Heavy pressure, crushing, or squeezing. Precipitators - exertion or stress. Relievers - Rest or nitroglycerin.
GI: History - gastritis or indigestion. Type of pain - burning. Precipitators - food. Relievers - antacids.
MSK: History - Trauma. Type of pain - Sore, achy, sharp. Precipitators - physical movement. Relievers - Rest, heat or pain.

Question 17

Differentiating Chest Pain Atypical presentations

Answer 17

Associated symptoms
• Women (main presentation is CP)
• Elderly
• DM
• SOB without CP (“anginal equivalent”)