Chest Pain in PC (Jaynstein) (Midterm) Flashcards
1
Q
What are the 5 basic differential topics to consider when a Pt presents with CP?
A
- Cardiovascular
- Trauma/MS
- Pulmonary
- Infectious
- Other
2
Q
Within the cardiovascular CP differential, what must you consider?
A
- ACS (Acute Coronary Syndrome)
- AAA (Abdominal Aortic Aneurysm)
- AS (Aortic Stenosis)
3
Q
Pts with Aortic Stenosis are S.A.D. because?
A
They experience _S_yncope, _A_ngina, and _D_yspnea
4
Q
Within the Trauma/MS CP differential, what must you consider?
A
- Chest wall Pain (Fx’s or contusions)
- Pneumothorax
- Boerhaaves syndrome (spontaneous perf of esophagus)
- Costochondritis
5
Q
Within the Pulmonary CP differential, what must you consider?
A
Pulmonary Embolism
6
Q
Within the Infectious CP differential, what must you consider?
A
- Pleurisy
- Pneumonia
- Myocarditis
7
Q
Within the Other CP differential, what must you consider?
A
- GI - GERD
- Esophageal
- PUD
- GB
- Psych
- Toxicity
Remember, consider a system above and below.
8
Q
What drug often causes CP?
A
Cocaine
9
Q
Should Psych causes of CP be your go-to assumption?
A
NO! No matter how anxious or psychotic a Pt may seem do not assume their CP is psych related until you have ruled out other more serious causes.
10
Q
Which two of the CP differentials can be hard to distinguish given clinical presentation, and warrant investigation of both as a cause of CP?
A
ACS and PE
11
Q
What percentage of Pts presenting with CP to a PCP have unstable heart disease?
A
1.5%
12
Q
What is the most common cause of CP in Pts who present to their PCP?
A
Chest Wall Syndrome (CWS)
13
Q
Of the 8 million Pts who present to an ED for CP which percent are Dxed with ACS?
A
13%
14
Q
Chest wall syndrome is an umbrella term for?
A
Musculoskeletal chest pain (think chostochondritis)
15
Q
If a provider says a Pt has nonspecific chest pain what do they mean?
A
That the CP is not related to coronary problems.
16
Q
What is the main goal when assessing a Pt with CP in the primary care setting?
A
Determine who is stable vs. who is unstable
17
Q
When determining who is stable vs unstable what are your 3 goals?
A
- Who is low risk?
- Who needs referral/testing? (Risk for MI in 90 days, needs preventative treatment)
- Who needs prompt transfer? (Currently unstable, get to ED STAT)
18
Q
If there are ever any concerns for the ABC’s (Airway, Breathing, Circulation) what should you do?
A
Immediately send to ED
19
Q
A Pt with CP, who shows NO signs of respiratory distress and has vital signs that are within “acceptable range” is?
A
Unlikely to be acutely unstable and is safe to evaluate in the office. Get a complete H&P.
20
Q
A Pt’s ABC’s are okay and vitals are acceptable to you, what is the first step in proceeding with the H&P?
A
Get an ECG
21
Q
If your office does not have an ECG machine what now?
A
You should not be evaluating a Pt with CP in an office without an ECG, send them to the ED.
22
Q
What are good questions to ask a Pt who presents with CP?
A
- Are you currently having chest pain?
- What were you doing when it started?
- What seems to bring the pain on?
- Have you had pain like this before?
- How long did it last, what made it go away?
- Is it worse with activity?
- Have you ever had a heart exam/workup before?
- Have you taken an aspirin today?
23
Q
When asking what were you doing when the pain started and what seems to bring the pain on, you are assessing what?
A
Whether the pain is brought on by exertion. If the pain was brought on by exertion and went away with rest this shows stable angina while if the pain came on suddenly while the Pt was relaxing is much more concerning for an unstable condition.
24
Q
What question do many providers forget to ask?
A
Have you had pain like this before? If yes, were you evaluated for it? What testing was done?
25
When is a Pt unlikely to need to undergo another cardiac workup/stress test?
If they have had one done in the last 90 days.
26
What is the goal of treadmill cardiac stress testing?
To find evidence of occlusive disease. If one was done in the previous 90 days it is next to impossible a Pt will have developed an occlusive disease since then.
27
If a Pt says they have taken an aspirin today what should your follow-up be?
Did you take a baby aspirin or a full-dose aspirin?
28
Pts with ACS should take a baby aspirin or full dose aspirin?
Full dose
29
How many baby aspirins equals a full dose aspirin?
4
30
CP after eating large meals points to what cause?
GI
31
CP after exertion points to what cause?
Cardiac
32
CP after exposure to cold, experiencing emotional stress, or after sex points to what cause?
Cardiac
33
What symptom of CP would point to an esophageal origin?
If the CP is worse with swallowing
34
If body position, movement, and/or deep breathing make CP worse what should you think?
The origin of the CP is likely musculoskeletal.
35
If CP is relieved after eating or taking an antacid it is?
Likely due to a Gastro-esophageal origin
36
If CP is relieved after taking sublingual nitro that means it is definitely a cardiac cause right?
Nope! Nitro causes smooth muscle relaxation, meaning heart muscle will relax but so will esophageal muscle, so it does not help with diagnostic eval.
37
You give a Pt a GI cocktail (viscous lidocaine and antacid, possible H2 blocker or PPI) and their CP goes away, must have been a GI cause for their pain right?
Nah, could be cardiac too, does not help with diagnosis.
38
Cessation of CP with rest indicates?
Probable cardiac cause.
39
CP with sitting up and leaning forward is a classical sign of?
Pericarditis
40
What do the following associated symptoms of CP point to? (lots of options)
* Belching, bad tatse in mouth, dysphagia
* Vomiting
* Diaphoresis
* Syncope
* Near-syncope
* Fatigue
* Belching, bad tatse in mouth, dysphagia
* Esophageal disease
* Vomiting
* MI or GI problems
* Diaphoresis
* Is a concerning sign regardless of what is going on.
* MI more likely than an esophageal disease
* Syncope
* Dissection, PE, critical AS, ruptured AAA
* Near-syncope
* Myocardial ischemia
* Fatigue
* May be presenting symptom of MI, especially in the elderly.
41
A diaphoretic Pt with CP is?
A bad omen, likely cardiac in origin.
42
If a Pt states that their CP radiates to their arms is this a strong predictor of an acute MI?
Yes
43
A Pt states their CP radiates to the area between their scapulae, what should you consider?
Aortic dissection
44
A large area of chest pain (think Pt gestures to their entire chest) is concerning for what?
Ischemic etiology of pain.
45
If a Pt can take one finger and point to their exact area of pain is this more or less concerning than someone with diffuse chest pain?
Less concerning, less likely to be due to an ischemic cause.
46
Is the severity of pain a good predictor of the presence of CAD?
No
47
Acute onset of CP with the greatest intensity at the beggining should make you think?
PTX, dissection, or PE
48
Gradual onset of CP that increases over time should make you think?
Ischemic cardiac pain
49
CP with a crescendo pattern (coming and going) is often caused by?
Esophageal disease
50
If CP last for seconds or is constant over the course of weeks is it likely an ischemic etiology?
No, ischemic pain usually lasts several minutes.
51
If CP has a circadian rhythm (morning worse than afternoon) is it likely due to ischemia?
Yep, this is due to increased sympathetic tone in the morning.
52
True or False: Heart attacks are more likely to occur in the morning just after waking up than in the afternoon?
True
53
Which histories are likely to be contributory to the frequency of CP?
* CV History
* If Pt has a history of previous MI they are more likely to have another.
* GI History
* Pts who have had biliary colic in the past but still have a GB are likely to experience biliary colic again
* Family History
* If a Pt has a strong family history of cardiac disease they are much more likely to experience cardiac problems.
54
If a Pt has had a previous MI and comes in complaining that their current chest pain feels the same or worse as when they had their last MI, they are?
Having an MI until proven otherwise. Get them to the ED.
55
Risk factors for CP?
* Tobacco use
* Family Hx
* DM/HTN/Lipids
* Cocaine (unlikely to be the cause of ACS)
* Previous history of DVT/PE (increases risk for future VTEs)
* Marfans/Pregnancy (Increase risk for aortic dissection)
* ETOH
* NSAIDs
* Age????
56
Is age a risk factor for cardiac causes of CP?
Yes and no. While the risk of cardiac causes for CP increase with age, younger and younger people are presenting with MIs. Do not assume because a Pt is young that they can't be having an MI.
57
Does a lack of risk factors for cardiac disease rule out a cardiac cause for a Pts CP?
Nope
58
What exam findings point to ACS?
* New S3 or S4
* Systolic BP \<80 mm/Hg
* Hypotensive MI is much worse than hypertensive MI, Hypertension means there is adequate perfusion, hypotension means bad perfusion and death.
* Crackles on auscultation
* Bad prognosis
Remember the absence of these does not mean ACS isn't present.
59
A likelihood ratio of greater than 1 indicates?
The test result is associated with the disease.
60
A likelihood ratio of less than 1 indicates?
The test result is associated with the absence of the disease.
61
If the likelihood ratio (LR) is 2, 5, or 10 it increases the probability the Pt has the disease by what percent?
* LR=2 increases the probability Pt has the disease by 15%
* LR=5 increases the probability Pt has the disease by 30%
* LR=10 increases the probability Pt has the disease by 45%
62
A likelihood ratio of what is considered highly significant?
LR\>10
63
Which symptom of CP has the highest likelihood ratio (LR) of being caused by an MI?
* CP that radiates to both arms (LR=9.7) indicates there is about a 50/50 chance they are having an MI.
* In contrast, CP that radiates to the left arm (LR=2.2) has about 15% chance of MI or the right shoulder (LR=2.9) about 20% chance of MI.
* Not sure if we need to know specific LRs but Jaynstein seems to like them.
63
What features decrease the likelihood of a MI?
* Pleuritic pain (LR=0.2)
* Sharp or Stabbing pain (LR=0.3)
* Positional pain (LR=0.3)
* Reproducible pain (LR=0.4)
LR less than 1 are associated with the disease not being present.
64
Symptoms indicating a high likelihood of ACS?
* CP radiating to one or both arms
* CP associated with exertion, nausea, vomiting, or diaphoresis
* CP described as pressure or as “worse than pervious angina or similar to previous MI”.
65
Symptoms indicating a low likelihood of ACS?
* Stabbing, pleuritic, or positional CP
* Pain in an inframammary location
* Pain not associated with exertion
* Pain reproducible with palpation
66
The Marburg Heart Score does what?
It helps to rule out CAD in CP Pts. It has a high negative predictive value (rule out CAD) but a low positive predictive value (Rule in CAD).
67
What are the criteria of the Marburg Heart score, each is worth 1 point (max points: 5) (She said in the PPT we don't need to memorize this)
* Women \>64 years, Men \>54 years
* Known CAD, CVD or PAD
* Pain worse with exercise
* Pain not reproducible with palpation
* Patient assumes pain is cardiac
68
A Marburg Heart Score of 2 or less indicates what?
98% of Pts with a score of 2 or less will **NOT** have CAD
69
Is a Pt with a Marburg Heart Score (MHS) of 5 more likely to have CAD than a Pt with a score of 3?
Not necessarily, the MHS has a low positive predictive value meaning it is not good for predicting the likely hood of having CAD, rather it is useful in predicting the likelihood of not having CAD. Only 23% of Pts with an MHS score of 3 or more have CAD; while 98% of Pts with an MHS score of 2 or less do not have CAD.
70
What are the acute MI criteria when looking at an ECG?
ST-elevation \>2mm in continuous leads
71
What are the ischemia criteria when looking at an ECG?
* Large Q wave \>2mm in inferior leads
* ST-Depression in continuous leads
* T-wave inversion in continuous leads
72
You get an in-office ECG that has concerning findings, what do you do next?
Send to ED for further eval
73
Your in-office ECG is non-diagnostic but you are still suspicious that the Pts CP may be from CAD what needs to be done?
Further testing with cardiac biomarkers (troponin) to evaluate from NSTEMI, get them to the ED for this.
74
Your ECG comes back normal in a CP Pt who you don't suspect has CAD. When might you consider getting a chest radiograph?
If they have CP and evidence of respiratory disease \*cough, dyspnea, Hx of pulmonary disease).
75
Should a troponin be done as an outpatient?
No right or wrong answer depends on the provider. In general probably best to send to the ED for the test.
76
What are the guidelines for ordering an outpatient troponin?
None exist but should meet the standard of care of the ED.
If CP has been resolved completely for greater than 3 hours and a troponin comes back negative you are done with the workup they are not having an MI.
If chest pain has not been completely resolved for more than three hours when the troponin is drawn, will need to get a second one an hour after the first was drawn. If these standards cannot be met in the outpatient setting, don't draw a troponin outpatient.
77
So when **is** it reasonable to draw a troponin outpatient?
Straight from the slides: “It is reasonable to use a single troponin test in general practice to exclude the possibility of acute myocardial infarction (AMI) in asymptomatic patients whose symptoms resolved at least 12 hours prior, so long as they have no high-risk features and a normal electrocardiogram.”
78
What does HEART stand for when obtaining the HEART score?
* **_H_**istory
* **_E_**CG
* **_A_**ge
* **_R_**isk Factors
* **_T_**roponin
Remember a HEART score can only be done in an EM setting when a trop can be obtained.
79
Jaynstein's final thoughts on CP?
* Nitro response is **not** diagnostic
* Post-prandial pain may be ischemic
* Discomfort thresholds vary
* Patient histrionics may influence you
* “atypical” is typical of something
* Value of the careful history and physical
80
List some emergent causes of CP
* ACS
* Aortic Dissection
* PE
* PTX
81
Classic findings of ACS
* Normal exam
* Tachycardia
* New murmur
82
Classic findings of Aortic Dissection
* Distressed
* NL EKG
* CXR: Wide mediastinum
* Pulse defects
* Neuro findings
83
Classic findings of PE
* Hypoxia
* Tachycardia
* EKG: Sinus tach, RBBB
* S1Q3T3 (uncommon but if seen means they have a PE)
84
Classic findings of PTX
* Tracheal shift
* CXR: Lucency
* Shock if TPTX
85
Name some urgent cause of CP
* Pericarditis
* Pulmonary HTN
* Myocarditis
* Esophageal Rupture
* Biliary Tract Disease
* Pancreatitis
* Pneumonia
86
Name some other cause of CP
* GERD
* PUD/Gastritis
* Esophageal Spasm
* Costochondritis/Chest Wall Syndrome
* Herpes Zoster
* Anxiety
87
Classic findings of Pericarditis
* Friction rub
* EKG: Diffuse ST-elevation
88
Classic findings of Pulmonary HTN
* Elevated JVP
* Loud P2 and S4
* CXR: Increased markings
89
Classic findings of Myocarditis
* +/- elevated trop
* Leukocytosis
* New murmur
* Tachycardia
* HF
90
Classic findings of Esophageal Rupture
* CXR: Mediastinal air
* “Crunch” crepitus
91
Classic findings of Biliary Tract Disease
* Murphy sign
* +/- Jaundice
* Fever
* Abnormal LFTs
92
Classic findings of Pancreatitis
* Elevated Lipase/Amylase
* Elevated LFTs if gallstone
93
Classic findings of Pneumonia
* Fever
* Leukocytosis
* Rhonchi/Rales
* CXR: Infiltrate
94
Classic findings of GERD
* Relived by GI cocktail (Be careful could still be MI)
* Cardiac w/u negative
* EGD: Esophagitis
95
Classic findings of PUD/Gastritis
* Epigastric tenderness
* Guaiac positive stools
96
Classic findings of Esophageal Spasm
* Better with nitro (could still be an MI)
97
Classic findings of Costochondritis/Chest Wall Syndrome
* Localized Tenderness
98
Classic findings of Herpes Zoster
* Pain before rash
99
Classic findings of CP related to anxiety
* It's a diagnosis of exclusion
