Chest Pain DSAs Flashcards
If a patient presents with chest pain, what are 2 questions you should be sure to ask?
- Frequency
- Does it wake you up at night
Risk factors for CVD
Age:
___ is a major risk factor
Other: HTN, hyperlipidemia, smoking, sedentary/obestity, family Hx, stress, sleep disturbances
Men over 55 YO; Women over 65 YO
DM
What are the 7 SERIOUS potenially lethal causes of Chest Pain?
- 1. M. ischemia
- 2. MI (acute-AMI); STEMI/NSTEMI
- 3. Aortic dissection
- 4. PE
- 5. Tension pneumothorax
- 6. Esophageal rupture
- 7. Pericarditis (effusion/tamponde)
PE findings associated with CV disease?
S4 gallop is heard _____
S3 gallop is heard _____
- Xanthema in eyes and elbows
- Nicotine stains on fingers, hair, odor
- Bruits (turbulent sounds)
- S4 gallop: angina
- S3 gallop: heart attack
- Mitral regurg, often due to dysfx of papillary muscle
- Diaphoresis
What can mimic angina in the absence of CAD?
1. Aortic insuff/ aortic stenosis/ Pulmonary HTN
2. Hypertrophic cardiomyopathy
3. Coronary spasm
4. HF
Differential dx of a STEMI?
- Pericarditis, myocarditis
- Stress induced Takotsubo cardiomyopathy (mimics ACS, LV apical balloning)
- Early ventricular repolarization in healthy patients, esp in AA
What can increase troponin level?
- Damage to myocardium
- Contusion, surgery, shock
- cardiomyopathies, HF
- Aortic dissection, AI, severe AS
- Tachycardia
- Pulmon: PE, pulm HTN, RF
- Renal: renal failure, shock
- Neurogenic: stroke or intracranial hemorrhage.
What will CBC show with STEMI?
mildly elevated WBC
- check troponin and CK-MB
CMP Panel shows what?
electrolytes, Mg, Ca, BUN, LFT
When are BNP levels increased?
- HF
- Stress to wall of ventricle d/t too much fluid
CRP may be ______ in STEMI?
increased
What is the initial stress test should we do if STEMI?
- Treadmill excercise
Then, stress echo to look at motion of wall, valve function and monitor cardiac rhythm.
When should pharmacologic stress testing be done w CP?
What are they?
When patient cannot excercise
- Vasodilator nuclear perfusion (via adenosine or regadenoson)
- Dobutamine nulcear perufsion (if cannot tolerate vasodilator or excercise)
- Dobutamin echo
What imaging should be done when a patient has chest pain?
- CXR
- Echo
- Cardiac MRI to look at thickness of wall and size of chambers.
Supply angina is caused by what?
Decrease in O2 supply to the heart due stenosis, vasoconstriction, causing platelets to release 5HT and TXA2 => platelet aggregation
Demand angina is caused by what?
<3 needs more O2 due increased workload => ischemia
- stress, excerise, fever, thyrotoxicosis, LVH due to AS, anemia
What are symptoms of stable angina?
Pattern of pain?
- Chest pain on exertion, emotion, stress that lasts 5-15 minutes and is relieved by rest of nitro.
- Does not change in freq, duration or intensite
What does a patient with stable angina show on ECG?
- 50% have NL ECG
- -ST depression/ST elevation
What is a unstable angina?
- ACS (acute coronary syndrome) that causes CP due to rupture of a atherosclerptic plaque => platelet aggregation and thrombus formation that partially occludes the artery.
- Increase frequency, severity, lasts longer than 15-20 minutes that occurs at rest/less effort.
NSTEMI myocardial infarction (NSTEMI) is distinguished from unstable angina by…
NSTEMI will have:
- High levels of cardiac enzymes (troponin/CKMB)
- Biomarkers of myocyte necrosis
What does NSTEMI look like on ECG?
- ST depression
- T wave inversion
How do we treat stable angina?
- 1. Low sat/trans fat diet, low Na+ diet, lose weight
- Nitroglycerin as needed for CP; 1 sublingual tab/5min; do not take 3 in a row.
- Long acting nitrates, B-blocker, CCB for coronary spasm, aspin, ACE-I
How do we treat ACS (unstable angina/NSTEMI)?
- Nitroglycerin, B-blocker, ASA, statin
- ACE-I
- Platlet ANT/aNTi-coag
What is a STEMI?
- ST-elevated MI: Thrombus formed by erosion, fissure or rupture of plaque that completely interupts flow to heart (transmural)
- D/t; atherosclerosis**, coronary spasm, vasculitis, dissection
What is the ECG criteria for a STEMI?
- ST elevation in 2 continguous limb leads
- or
- 2 mm ST elevations in 2 continous precordial leads or new LBBB
Describe the pain in a STEMI?
- More severe than angina and cannot be relieved by NTG or rest
- substernal => neck/jaw => left arm
- N/V, SOB, sweating
Are all STEMIs painful?
20% are painless, esp in elderly female with DB
How do we treat STEMI?
- Hospital + cardiac catheterization
- PCI (percutaneous coronary intervention) or fibrinolytic therapy (clot buster)
Valvular heart disease most commonly are due to what?
Senile calcification/degeneration.
Other: myxocmatous degernation (MVP) or congenital (BAV)
Murmurs are a result of what?
- Tubulence across valve
- Increase blood flow (anemia/pregnancy)
Stenosis creates ____ overload, causing what?
- Pressure overload
- Hypertrophy and HF
Regurg creates ____ overload, causing what?
VOLUME
Dilates heart
List the 5 valvular causes of systolic murmurs
MR P.V. TRAPSS
- Mitral regurg/prolopase
- VSD/ASD
- Triscupid regurg
- Aortic stenosis
- Pulmononis stenosis
last s = stenosis
List the 4 valvular causes of DIASTOLIC murmurs
MSTS PAID “mistess paid”
- Mitral stenosis
- Tricuspid stenosis
- Pulmonary insuf/regurg
- Aortic insuf/regurg
Diastolic
Murmur grade scale (1-6)
- Barely audible
- Soft/faint
- Louder, easily heard
- Very loud + palpable thrill (vibration)
- Heard with stethoscope barely touch chest + thrill
- Can hear w/o steoth or close to chest + thrill
pt comes in and murmur is very loud with palpable thrill.
what grade
4
What are the 2 etiologies of chronic mitral regurgitation (MR) and which is most common?
- Mitral valve prolapse = MOST common-
- Myxomatous/ degeneration or mitral annular calcification (MAC)
What are 4 causes of acute mitral valve regurgitation?
Which is 2nd most common cause of MRregurg?
- Rupture of chordae tendineae
- Rupture of papillary muscle
- Ischemic papillary muscle dysf. due to CAD/MI
1. 2nd most common cause
- Ischemic papillary muscle dysf. due to CAD/MI
- Infective endocarditis(IE); valve perforation
Systolic murmur (blowing, holocystolic) that is best heard at apex => radiates to L axilla
Mitral regurg
What is MVP?
1 or both leaflets prolapse into atrium d/t myxedematous degeneration
Which sex is most often affected by mitral valve prolapse (MVP) and what are congenital defects which increase risk?
- Women 7:1
- Assoc. with Marfans/skeletal changes
What are the range of sx’s/signs associated with MVP?
- Asymptomatic to [arrhythmias (SVT, PVC’s, VT), chest pain and/or syncope]
F pt presents to office with hx of palpitations, dizziness, scared of habing a heart attack.
what kind of murmur is thought to be there
MVP
What is the characteristics of the murmur heard with MVP?
Systolic murmur heard best at the apex that may have a systolic click
will incrrease with valsalva and standing
Systolic murmur heard best at the apex that may have a systolic click
will incrrease with valsalva and standing
MVP
If patient with MVP is in hyper-adrenergic state (anxious, palpitations), consider using what drug class?
Beta-blocker
What are 3 causes of Aortic Stenosis and which is most common?
- Most common = Degeneration calcification of valve (—> persons >65 yo
- Congenital or acquired bicuspid aortic valve (BAV)
- Rheumatic/post-inflammatory scarring (radiation)
Which decade does aortic stenosis typically manifest in and what are the 4 cardinal signs/sx’s?
- - 6th decade
- - Exertional dyspnea
- - Angina
- - Syncope
The obstruction in aortic stenosis leads to what type of overload (pressure/volume) and what are the downstream effects?
PRESSURE overload –> LVH –> ↑ pressure= diastolic dysf + systolic HF
What are the common PE findings of aortic stenosis (i.e., pulse pressure, SV and systolic pressure)?
- NARROW pulse pressure
- Decreased SV and systolic pressure
- Delayed pulses --> Parvis (weak w/ ↓ amplitude) or Tardus (late/delayed)
What are the characteristis of the murmur heard in aortic stenosis (heard best where, radiates)?
Affect on S2 sound?
- Systolic murmur (crescendo-decrescendo) that is harsh at 2nd ICS at RSB => radiates to sternal notch and carotics
- Decreased S2
What will we see on ECG with aortic stenosis?
LVH and strain pattern (down-sloping of ST segment - Twave)
BAV is associated with what diseases?
Marfans
Turners
where is pulmonic stenosis heart at?
Sytolic murmur (crescendo-decrescendo) heart best at the 2-3 ICS at the LSB => radiates to left shoulder/clavicle.
Pulmonic stenosis may be assx with what?
Tetralogy of fallot: PS, VSD, RVH and overriding aorta
What dose a VSD murmur sound like?
Holosytolic murmur heard best at the lower left sternal border with thrill.
L-> R shunt Increases with handgrip
What dose a ASD murmur sound like?
-
Systolic murmur at the upper LSB with fixed splitting of S2
- L => R shunt
- Mitral/ tricuspid stenosis
- Aortic/pulmonic regurg
The narrowing of the mitral orifice seen in MS, leads to an increased pressure gradient where and what other changes?
- ↑ left AV pressure gradient
- LA enlargment –> afib, pulmonary vascular changes, RVH
Most common presenting sx’s of someone with mitral stenosis (MS)?
- Fatigue d/t. decreased CO
- Dyspnea on exertion, cough, orthopnea, PND, pulmonary edema, hemoptysis
What is Ortner syndrome associated with MS?
Hoarsness due to compression of left recurrent laryngeal n. as LA ↑ in size
Describe the murmur associated with MS (i.e., phase of cardiac cycle, best heard where/position and with what part of stethoscope)?
- DIASTOLIC, low pitch, decrescendo, rumbling murmur
- Best heard at APEX w/ pt in left lateral decubitus position
- Use BELL
What are the ausculatory findings of S1 and S2 in pt with MS?
↑ loud S1 + ↑ S2 (P2 if PHT is present)
- Opening snap after S2 (if leaflet is mobile)
Common EKG finding of someone presenting with sx’s of severe MS?
Atrial fibrillation
If person with mitral stenosis is in sinus rhythm, they will have _____
Left atrial enlargement
- *‘M’ shaped ‘p’ wave = P mitrale
What type of murmur is associated with Tricuspid Stenosis and where is it best heard?
What causes an increase and decrease in the murmur?
- DIASTOLIC, LOW pitch, decrescendo murmur at LSB
- Increase w/ inspiration (Carvallo’s sign)
- Decrease w/ expiration and valsalva
Which wave in JVP is Tricuspid Stenosis vs. Regurgitation associated with?
- TS = prominent “A” wave in JVP
- TR = V wave in JVP
What will we see on ECG with Tricuspid stenosis?
Right atrial enlargement
Most causes of pulmonic regurgitation (PR or PI) are due to what?
Pulmonary HTN
What is the characteristic murmur heard with Pulmonic Regurgitation and heard best where?
DIASTOLIC, decrescendo blowing murmur at 2nd ICS LSB = Graham Steell
There will be an increased P2 if pulmonic regurgitation is due to what?
Pulmonary HTN
