Chest Pain Clinical Reasoning Flashcards
What is the classic presentation of stable angina?
Substernal exertional chest discomfort
Sxs resolve promptly with rest or nitroglycerin and do not change over the course of weeks
Usually pt has CHD risk factors
What is the cause of stable angina?
Mismatch between myocardial oxygen supply and demand.
Common first presentation of coronary heart disease (CHD) usually due to coronary artery stenosis
What are the important tests for workup of stable angina?
cardiac stress test, CT coronary angiogram, or angiogram
Laboratory testing: blood glucose and lipid panel to look for diseases which increase likelihood of ischemic process
What are the risk factors for CHD? (important to ask for chest pain workup)
male sex
age >55 yo in men, >65 yo in women
tobacco use
diabetes mellitus
hypertension
abnormal lipid profile
other: other vascular diseases, CKD, elevated inflammatory markers, lifestyle factors (sedentary, obesity, etc), cocaine use
How might women describe angina differently than men?
More likely to use terms like “burning” or “tender”
What 3 questions should you ask to categorize a patient’s chest pain as either typical angina, atypical angina, nonanginal?
- Where is your pain? (substernal = pos)
- Does your pain come on or get worse when you walk, walk fast, or climb stairs? (exertional = pos)
- Does your pain get better with rest? (yes = pos)
If all 3 positive screen –> typical angina
If only 2 positive –> atypical angina
If only 1 positive –> nonanginal chest pain
What do stress tests do?
attempt to induce and detect myocardial ischemia (can use exercise or drug induced if needed, ex. dobutamine)
Other than exertion, what are two triggers for stable angina?
Emotional stress, cold weather
How would you decide between a stress test or angiography for further workup for suspected stable angina?
Pt with high likelihood of disease may not benefit from stress test bc the test is not needed for diagnostic purposes or they may not be able to undergo revascularization
Angiography is the gold standard for diagnosing CHD. Indications are abnormal stress test indicating substantial ischemia, ischemia at a low workload on exercise test, diagnostic uncertainty.
Can move straight to angiography without stress test if sxs are disabling despite therapy or if they have heart failure
How can you treat stable angina?
Tx goal = relieve sxs, inhibit disease progression
- Lifestyle modification (smoking cessation, exercise, weight loss, low fat and low cholesterol diet)
- Medication to treat sxs:
- Beta blocker (first line, decrease oxygen demand)
- Nitrates (increase coronary blood flow, short acting used to relieve episodes)
- Medication to slow sx progression:
- aspirin
- high intensity statin
- BP control if pt has HTN
- ACE-I/ARB in patients at highest risk (ex. diabetes, heart failure)
- gylcemic control
What is the classic presentation for GERD?
heartburn (burning, substernal, chest discomfort), regurgitation, dysphagia, symptoms worse at night and after large meals, worse lying down
(note dysphagia raises possibility of obstructing lesion and mandates prompt eval, usually with upper endoscopy)
What factors typically make GERD symptoms worse? (aggravating factors)
- ingesting large (esp fatty) meals
- lying down after meal
- using tobacco
- eating foods that relax lower esophageal sphincter (chocolate, alcohol, coffee, peppermint)
How can you diagnose GERD?
suggestive symptoms and response to therapy generally considered diagnostic
EGD can be done in pts with alarm symptoms (dysphagia, odynophagia, weight loss, GI bleeding, iron deficiency anemia) or signs suggestive of complicated disease (early satiety, vomiting, extra-esophageal symptoms, unclear etiology of chest pain, longstanding sxs - to check for Barrett esophagus, require long term therapy, respond poorly to appropriate therapy)
what is the treatment for GERD?
8 week course of once per day proton pump inhibitor (PPI) = first line
H2 receptor blockers can be used for maintenance therapy (not initial tx)
motility agents may also be useful (not initial tx)
what is the classic presentation for acute MI?
Middle aged man with risk factors for CHD with crushing substernal chest pressure, pain radiating to left arm, diaphoresis, nausea/vomiting, shortness of breath, feeling of impending doom
*Note: we do a bad job at recognizing (and historically studying) MI in women, younger and older patients. There are also frequent atypical presentations
When does an MI happen?
prolonged failure to perfuse an area of myocardium leading to cell necrosis
what is the most common etiology of an acute MI?
coronary plaque ruptures causing thrombosis and subsequent blockage of a coronary artery
what are the broad differences between STEMI and nSTEMI?
STEMI
- transmural ischemia or infarction
- typically caused by complete occlusion of coronary artery
- initial diagnosis requires strict ECG criteria
nSTEMI
- less severe, usually injuring only subendocardial tissue
- typically caused by incomplete occlusion of a coronary artery
- higher subsequent risk for STEMI than for pts with STEMI
What is the first initial step for workup if suspected MI?
Next step?
EKG within 10 minutes of arrival to ED!
Obtain peripheral blood sample to check CK-MB and troponin
What cardiac biomarkers are measured in suspected MI?
serum creatine kinase MB subunit (CK-MB)
troponin
how can kidney disease affect troponin levels?
may be elevated (increased risk false positives)
How can MI present in women specifically?
- more likely to present without chest pain
- often report prodromal sxs (fatigue, dyspnea, insomnia)
- dyspnea, weakness, fatigue common sxs
what would the expected findings be for STEMI on EKG?
ST-segment elevation/depression, T-wave inversions, Q waves
What is the classic presentation for unstable angina (UA) or nSTEMI?
new or worsening sxs of CHD, only differentiated by absence (UA) or presence (nSTEMI) of myocardial enzyme elevation in peripheral blood samples
what distinguishes unstable angina from stable angina?
UA is angina that is new, worsening in severity or frequency, or occurs at rest
what is the pathophysiology of UA or nSTEMI?
primarily caused by acute plaque rupture followed by platelet aggregation
what are the 3 presentations of UA?
- angina at rest
- new onset (<2 months) angina
- increasing or accelerating angina
what are some features/findings that increase likelihood that a patient’s sxs represent an ACS (ie unstable angina or nSTEMI)?
chest pain or L arm pain that reproduces prior angina
hx of CHD
transient mitral regurgitation murmur
hypotension
diaphoresis
pulmonary edema
crackles
what are the classic EKG findings of UA/nSTEMI?
nonspecific changes, including T-wave inversions, ST-segment depressions
what is the acute treatment for UA/nSTEMI?
oxygen, aspirin, enoxaparin, clopidogrel, beta blocker, nitrates
urgent coronary angiography if unstable patient
what is the classic presentation of aortic dissection?
older man with hx of hypertension and possibly atherosclerotic disease who complains of “tearing” chest or back pain
Pain may be associated with vascular complications (syncope, stroke, cardiac ischemia, HF secondary to acute aortic regurgitation(
Physical exam: asymmetry in upper extremity BPs and the chest radiograph shows widened mediastinum
what is the pathophys (brief) of an aortic dissection?
dissection begins with a tear in the aortic intima allowing blood to dissect between the intima and media
what are 7 risk factors for aortic dissection?
- hypertension
- atherosclerosis
- known aortic aneurysm
- prior aortic dissection
- diabetes
- Marfan syndrome
- cocaine use (esp in younger patients(
what are symptoms of an aortic aneurysm (that has not dissected)?
can detect on chest XR
can also present with aortic regurgitation, pain, or impingement on other structures like trachea, esophagus, or recurrent laryngeal nerve
what are the 3 most important findings that would point to aortic dissection in a patient with chest pain?
- acute or tearing or ripping pain
- aortic or mediastinal widening (on chest XR)
- asymmetric pulse or BPs
what is the gold standard for diagnosis of aortic dissection?
what do most patients undergo for diagnostic testing?
angiography is gold standard
most patients undergo noninvasive tests (CT or TEE (transesophageal echocardiography))
what is the classic presentation of pleural effusion?
small –> usually asymptomatic
large –> dyspnea with or without pleuritic chest pain
often cough, shortness of breath, fever
presentation also depends on etiology. If parapneumonic, may also have signs/sxs of pneumonia. If neoplasm, HF, PE, or rheumatologic disease, may have sxs specific to those diseases
what is the differential for an exudative pleural effusion?
increased capillary permeability or disruption of pulmonary lymphatics
parapneumonic effusion, malignancy, pulmonary embolism (75%), viral infection, post CABG, subdiaphragmatic infections and inflammatory states, chylothorax/uremia/connective tissue diseases
what is the differential for transudative pleural effusions?
caused by increased hydrostatic pressure, decreased oncotic pressure, or increased negative intrapleural pressure
heart failure, cirrhosis with ascites, pulmonary embolism (25%), nephrotic syndrome, severe hypoalbuminemia
what physical exam findings are consistent with a diagnosis of pleural effusion?
dullness to chest percussion, area of egophony just superior to effusion
confirmation on chest XR, ultrasound, or other imaging
how can the Light criteria be used to determine etiology of pleural effusion?
effusion is exudative if any of the following are present:
- pleural fluid protein/serum protein > 0.5
- pleural fluid lactate dehydrogenase (LD)/serum LD > 0.6
- pleural fluid LD > 2/3 upper limit normal for serum LD
what should pleural fluid testing always include for workup of pleural effusion?
LD, protein, albumin, pH, cell count
what characterstics of a pleural effusion would warrant thoracentesis?
clinically significant effusion >1cm on chest film (unless suspected etiology of HF)
what is the classic presentation for patient with acute pericarditis?
young adult, 1 week of viral sxs and chest pain, pleuritic chest pain, pain radiates to trapezius ridge, improves with leaning forward, worse when lay down
Physical exam reveals friction rub, ECG reveals ST elevations and PR depressions in all leads
what are some causes of pericarditis?
viral
TB and HIV
post MI and post cardiac surgery
SLE, RA
medication induced: procainamide, hydralazine
malignancy that has metastasized to pericardium
chest irradiation
uremia
*however most are considered ~idiopathic~ or due to undiagnosed virus
how is pericarditis diagnosed?
characteristic pericardial friction rub
or
pt with chest pain and characteristic EKG findings (widespread ST elevations and PR depressions)
Once diagnosed, need to do echo to evaluate and exclude tamponade
are cardiac enzymes helpful in diagnosing pericarditis?
no! often positive and therefore not helpful in distinguishing chest pain of pericarditis from cardiac ischemia
what workup is indicated for pericarditis?
chest radiograph
BUN and Cr
TB test
antinuclear antibodies
blood cultures
what is the treatment for uncomplicated pericarditis?
NSAIDs for pain relief
tx is supportive
what are the characteristic clinical features of cardiac tamponade?
Tachypnea, dyspnea
Tachycardia
Pulsus paradoxus
Cardiogenic shock
Beck triad: hypotension, elevated JVD, muffled heart sounds
what are the characteristic clinical features of heart failure exacerbation?
Chest pressure
Cough, dyspnea
Hypoxemia
Crackles, JVD, peripheral edema
what are the characteristic clinical features of esophageal perforation?
Retrosternal chest pain, neck pain, epigastric pain with radiation to the back
Dyspnea, tachypnea, tachycardia
Dysphagia
Signs of sepsis
Mackler triad (chest pain, vomiting, subcutaneous emphysema)
Mediastinal crepitus
History of recent endoscopy or severe emesis (Boerhaave syndrome)
what are the classic clinical features of tension pneumothorax?
Severe, sharp chest pain
Dyspnea, hypoxemia
History of trauma
Hyperresonance, decreased breath sounds, tracheal deviation
Tachycardia, hypotension
what are the characteristic clinical characteristics of peptic ulcer disease?
Epigastric pain (may present as chest pain)
Duodenal ulcer: pain relieved with food; weight gain
Gastric ulcer: pain exacerbated by food; weight loss
Signs of GI bleed
History of NSAID intake
what are the characteristic clinical findings of pancreatitis?
Severe epigastric pain that radiates to the back (ie may present as chest pain)
Nausea, vomiting
Epigastric tenderness, guarding, rigidity
Upper abdominal pain
Hypoactive bowel sounds
History of gallstones or alcohol use
what are the classic clinical features of Mallory-Weis syndrome?
Epigastric pain that radiates to the back (ie may present as chest pain)
Repeated episodes of severe vomiting
Hematemesis
Melena, dizziness, syncope
what are the classic clinical features of pulmonary embolism?
Pleuritic chest pain
Acute onset dyspnea, hypoxemia
Cough, hemoptysis
Unilateral leg swelling or history of DVT
Hypotension, shock (if massive PE)
(although common presentation is asymptomatic)
what initial diagnostic testing can be used to diagnose pulmonary embolism?
D-dimer levels
what are the characteristic clinical features of costrochondritis?
Sharp, well-localized pain that is reproducible on palpation of costal cartilage
History of recent exercise/exertion/chest wall trauma
(clinical diagnosis, tx = pain management with acetominophen or NSAIDs, heat/ice packs, reduce activity that aggravates)
what are the characteristic clinical features of acute herpes zoster?
What is tx?
Severe burning or throbbing pain (can present as chest pain)
Thoracic dermatomes most commonly affected
Maculopapular rash that develops into a vesicular rash in a dermatomal distribution
Immunocompromised status
Tx = antivirals
what are the characteristic clinical features of panic disorder?
What are tx options?
Chest tightness, palpitations, tachycardia
Tachypnea
Diaphoresis, dizziness
Paresthesias
Anxious appearance
Recent stressful exposure
Tx: breathing exercises, can give benzodiazepines acutely
Describe the approach to a patient with a potentially life threatening cause of chest pain
List 6 risk factors for DVT/PE
- recent travel/prolonged immobilization
- smoking
- oral contraceptives
- malignancy
- recent surgery
- personal or family hx of clotting disorder
what are some important questions to ask for review of systems for chest pain?
nausea/vomiting, shortness of breath, hemoptysis, fever, sweating, syncope, bad taste in mouth, breathing faster than usual, palpitations, orthopnea, paroxysmal nocturnal dyspnea, LE edema
Describe the approach to chest pain in the ER in a patient NOT in severe respiratory distress or shock
from Dr. Mutharsan’s clinical correlation lecture
what are the classic features of chest pain with an MSK etiology?
very brief sharp, stabbing pain
localized (<3cm) dull ache
superficial chest wall location, worse with palpation
positional or pleuritic pain
worse with neck/arm motion
