Chest Pain, Heart And Lungs Flashcards
What is the incidence of chest pain or cardiorespiratory symptoms in the chiropractic setting?
In teaching clinics - 1-7%
Chest complaints - 3.8%
Heart murmur = rare
Angina or MI = rare
__% of chest pain patients in the ER will have acute coronary syndrome (heart attack or unstable angina)
10%
__% of patient with symptoms of acute cardiac ischemia will prove to have an MI
25%
__% of chest pain patients in a primary care medical office have unstable heart disease (emergency referral)
1.5%
Draw out the classification table of acute chest pain
(Pic)
What are the most common causes of chest pain in patients who seek care in primary care office?
MSK conditions = 29-36%
Gastrointestinal disease = 10-19%
Stable CAD = 8-10%
Psychosocial or psychiatric disease = 8-17%
A patient with chest pain who shows signs of respiratory distress or whose vital signs are abnormal (e.g., low Bp, weak or irregular pulse) may have an acutely unstable heart problem.
Call an ambulance
Can you differentiate CHD from GERD or chest wall syndrome based on location?
No
What are three ways to investigate the heart?
- Blood pressure
- Pulse
- Auscultate heart (listen to mitral valve while patient does Valsalva)
What are two ways to investigate the upper GI track
- Palpate/percussion upper quadrants (knees flexed)
- carefully include epigastric region
What are three ways to investigate the spine and body wall?
- Static and motion palpation of cervical, thoracic spine (include TLJ)
- palpate The ribs and back muscles
- Palpate The chest wall (include costosternal junctions, pectoralis, intercostals).
What are 5 ways to investigate the lungs?
- Observe respiratory rate
- Observe breathing, use of accessory muscles
- Palpate for fremitus
- Percuss
- Auscultate
What are some ways a heart attack can present?
- chest pain
- shortness of breath
- dizziness, weakness, syncope
- abdominal pain
Of those who die from a heart attack, most die within ___ hours of symptoms onset
The first two
What are 4 high risks for acute coronary syndrome?
- Chest pain which is exertional,
- Pain radiating to one or both arms,
- Pain similar > prior cardiac chest pain
- Or associated with nausea, vomiting, or diaphoresis.
What are low risks (4) for acute coronary syndrome, making it less likely? What are somewhat lower risks (2)?
- Pain is pleuritic (related to breath cycle)
- Pain is positional
- pain is reproducable with palpation (BEST CLUE)
- quality of pain is stabbing (if they can point to the location with one finger)
somewhat lower risks
- pain is not exertional
- pain in small inframammary area of chest
Where is the location for acute coronary syndrome?
- C3-T10
- down one or both arms
- in the middle of the shoulder blades
CLINICAL PEARL
Suspect cardiac angina in any patient who describes any discomfort above the waist that . . .
Is provoked by exercise and relieved by rest
What are associated symptoms questions to ask about chest pain?
- dyspnea
- dizziness
- diaphoresis
- nausea
- weakness/fatigue
- (near) syncope
- palpitations
What are modifiable risk factors for CVD? What is the prevalence of each?
Can these be used to rule out heart disease?
- Overweight or obese – 65%
- LDL cholesterol >130 mg/dL – 46%
- Physically inactive – 38%
- HDL cholesterol 40 mg/dL – 26%
- Hypertension – 25%
- Tobacco use – 25%
- Metabolic syndrome – 24%
- PREHYPERTENSION – 22%
- DIABETES MELLITUS – 8%
NO, Ex: 22% have hypertension but 78% do not so it’s absence does not rule out
What are non-modifiable risk factors for acute coronary syndrome?
- Male gender
- Family history
- Increased hsCRP (they are pro-inflammatory) (somewhat modifiable)
- HRT hormone replacement therapy (?)
- Increased coronary artery calcium
Describe what the test for increased coronary artery calcium is?
Not a blood test, it’s a specialized CT scan
What are ancillary studies for CAD RISK factors?
- Lipid profile
- Glucose/Hgb A1C/ 2 hour post load
- hsCRP
- Coronary artery calcium (CAC) (This is a CAT, Ancillary studies for CAD risk factors not a blood test)
What separates stable angina from a heart attack?
Brief ischemic episode without permanent heart damage
*no cardiac enzyme released into the blood
How do you diagnose angina? Atypical angina? Non cardiac chest pain?
Typical angina (definite)
- Substernal chest discomfort with a characteristic quality and duration
- Provoked by exertion or emotional stress
- Relieved by rest or nitroglycerin
Atypical angina (probable) Meets 2 of the above criteria
Noncardiac chest pain
Meets 1 or none of the above.
What are ancillary studies for suspected angina?
- 12 lead resting EKG (often normal; positive cannot confirm angina)
- Tests of choice: stress tests (EKG, echo,
myocardial perfusion scintigraphy). New: coronary computed tomography angiography (CCTA) & cardiac MRI - Chest radiograph (optional)
- Risk factor tests
- Angiography (gold standard)
How is a 12 lead resting EKG performed?
?
How is a stress EKG performed?
Hooked up to 12 leads while on a treadmill
How is a echo stress test performed?
Put on treadmill to get heart rate up
Immediately followed by Ultrasound over patients chest to visualize heart
How is a myocardial perfusion scintrigraphy performed?
- A dye is injected that accumulates in the heart
- Patient undergoes stress and then is scanned
- If there is an area without accumulated dye, there is a blockage there
What is the gold standard test for suspected angina?
Angiogram - needle inserted and injects dye into heart
What are three ischemic heart issues?
Stable angina, unstable angina, MI
If your patient as angina but it seems stable, what should you do?
Still treat it as unstable and have them go to their PCP today or tomorrow?????
What two dx make up acute coronary syndrome?
Acute MI
Unstable angina
What are signs for stable angina? (6)
- exertion related
- usually <10 min
- rest & nitro help
- ST depression on EKG
- negative enzymes
- due to athero
What are the signs of unstable & prinzmetal angina? (6)
- occurs at rest
- > 10 min
- nitro usually helps
- ST depression or elevation
- unstable due to complicated athero
- prinzmetal due to vasospasm
What are the top three clues from history that increase the probability of acute MI?
- nausea (+LR 10)
- both arms with pain (+LR 9.7)
- right arm pain (+LR 7.3)
*don’t memorize exact +LR #
Wen should you be more worried about heart disease based on history
If the patient stopped activity
What are physical exam findings of heart attack?
- third heart sound
- hypotension(SBP =80 mm Hg)
- pulmonary crackles
- diaphoresis
What are physical exam findings that DECREASE the probability of acute MI?
- pleuritic chest pain
- chest pain is sharp or stabbing
- positional chest pain
- chest pain reproduced with palpation
What makes you more suspicious of MI based on the Marburg Heart Score?
- women >64, men >54
- known CAD, cerebrovascular disease, or peripheral vascular disease
- pain worse with exercise
- pain not reproducible with palpation
- patient assumes pain is cardiac
What are ancillary studies for MI?
- 12 lead EKG (+LR 22, -LR 0.2) (still can’t rule out)
- troponins (a break down particle released from heart)
- cardiac enzymes (CPK-MB, AST)
What is the pattern of troponins and cardiac enzymes (CPK-MB, AST) after MI?
they raise after MI, peak around 12 hours, then are gone by around 24 hours
What are causes of chest pain? What are the big clues? What is the ancillary study?
Mitral valve prolapse
- BIG CLUE: hear a mid-systolic murmur or closing click (luv-swish-dub or click-dub)
- ancillary study: echocardiogram
Pericarditis
-BIG CLUE:
1 - non-pleuritic friction rub (sounds like when you grind your hair together) (have them hold their breath to ensure it’s heart and not lung)
2 - pre-cordial pain radiates to trapezius ridge
3***- aggravated by supine, relieved to bending forward
4 - with characteristic ECG changes
PLEURITIS
- BIG CLUES: pleuritic pain (worse with a deep breath/ timed with the breath cycle), Respiratory friction rub, may have fever/ malaise, follows pneumonia???, follows SLE????
- ancillary study: chest radiograph, CBC, blood chemistry, ESR
GERD
- ancillary studies: acid-suppression test
Gallbladder, duodenal ulcer
- palpate upper quadrants
Anxiety
- questionnaire
MFTP
Thoracic spine subluxation
How do you do perform an acid suppression test for GERD?
2 weeks, 40mg 2x/day, if it takes away chest pain it is GERD
What is the general screening test for SLE?
Ana = anti-nuclear antibody
What are the three questions for a panic disorder?
- when you are nervous, how often do you think, “I am going to pass out”?
- during the last 7 days, including today, hw much have you been bothered by pain in the chest?
- to what degree is your chest pain tiring or exhausting?
- 76% of patients with a score <4 will not have panic disorder and 71% of patients with a score of >5 will have panic disorder
What do you need to palpate when investigating musculoskeletal causes of chest pain?
?
What muscles may have MFTP’s? Where do they refer?
- Scalene
- pec major
- pec minor
- serratus anterior
How do examine muscular causes of chest pain?
Palpate, contract, stretch
