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LMCC Part II > Chest Pain/MI > Flashcards

Chest Pain/MI Flashcards

1
Q

what are the most likely etiologies of CP

A

CENTRAL

  1. cardiovascular–25% overall, 50% in older adults
  2. pulmonary/mediastinal–5%
  3. other–30%
    - -GI 20%
    - -neuropsychiatric–10%

PERIPHERAL

  1. chest wall pain–35%
  2. pulmonary–5%
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2
Q

what are the cardiovascular ischemic causes of CP

A

MI–> less than 2% in primary care (acute, evolving, recent, established

angina pectoris

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3
Q

what are the cardiovascular non-ischemic causes of CP

A

aortic aneurysm –dilating/dissecting (consider in HTN, cystic necrosis, marfan’s)

pericarditis –infectious, post MI, post CABG, uremic, connective tissue disease

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4
Q

what are the pulmonary/mediastinal central causes of CP

A

PE
tracheitis
mediastinal malignancy

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5
Q

what are the central GI causes of CP

A 
esophageal spasm
esophagitis/PUD
mallory weiss
biliary disease
pancreatitis
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6
Q

what are the central neuropsychiatric causes of CP

A

cardiac neurosis
anxiety
depression
somatoform

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7
Q

what cause chest wall CP

A

costochondritis

herpes zoster

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8
Q

what are the peripheral pulmonary causes of CP

A

pleuritis
pneumo
pulmonary infarct
malignancy

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9
Q

what are the five deadly causes of CP (mnemonic)

A

TAPUM

Tension pneumo
Aortic dissection
PE
Unstable angina
MI
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10
Q

what is the ACS spectrum

A

stable angina–> unstable angina–> NSTEMI–> STEMI

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11
Q

what is an MI

A

death of myocardial tissue from a relative or absolute insufficiency of blood supply

usually result of coronary artery thrombosis with myocardial necrosis 3-6 hours after onset (or less if sudden, complete occlusion and no collateral flow)

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12
Q

how soon after coronary occlusion with myocardial death occur

A

3-6 hours (or sooner)

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13
Q

other than coronary occlusion, what can cause an MI

A

cocaine

aortic dissection

malignant HTN

hypotension

anemia

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14
Q

what is unstable angina

A

angina pectoris which has recently changed in frequency, duration, intensity or occurs at rest

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15
Q

what is the typical MI presenting CP

A

crushing/squeezing retrosternal chest pain or pressure that radiates to neck/jaw/shoulder/arms associated with nausea, vomiting, diaphoresis, sense of impending doom

may be likened to heartburn

may be like typical angina only more severe and persistent, not relieved by nitroglycerin

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16
Q

how might MI pain differ in someone with DM

A

can be atypical or painless

  • can also be this way in women, the elderly
    i. e can present like CHF, confusion, dizziness, syncope, stroke, new arrhythmia
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17
Q

what are cardiac RFs

A 
previous CAD
HTN
DM
smoking 
family history (first degree relative younger than 55 with first MI)
DLD
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18
Q

what are you looking for on physical exam with MI

A

distress
cold, moist, pale
increased or decreased HR
hypotensive

may have faint heart sounds
S4 is usually present
new MR murmur

may have signs of CHF, including S3, crackles, elevated JVP

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19
Q

what investigations should you order for suspected MI

A

ECG–look for classic stepwise progression and “thrombolytic criteria”

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20
Q

what is the classic stepwise progression of MI on ECG

A

hyperacute T waves–> elevated ST segments with or without reciprocal ST segment depression–> inverted T waves–> may get Q waves

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21
Q

what are the thrombolytic criteria on ECG for MI

A

at least 1mm ST segment elevation in 2+ contiguous leads or new LBBB

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22
Q

what region is the MI in, if the ST elevation is in…?

V1 and V2

A

septal

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23
Q

what region is the MI in, if the ST elevation is in…?

I, aVL, V5, V6

24
Q

what region is the MI in, if the ST elevation is in…?

V3 and V4

25
what region is the MI in, if the ST elevation is in...? II, III, aVF
inferior if inferior pattern, look for right venticular involvement with right sided leads looking for ST segment elevation in V4
26
what region is the MI in, if the ST elevation is in...? ST depression in V1-V4
posterior
27
what is on the differential when you see ST elevation on an ECG
1. normal variant/early repolarization 2. ischemic heart disease 3. acute pericarditis 4. other causes--LVH, LBBB, advanced hyerkalemia, hypothermia
28
how does normal variant/early repolarization ST elevation look on ECG
usually conCAVE upwards ending wiht symmetrical, large, upright T waves
29
how does ischemic heart disease ST elevation look on ECG
usually conVEX upwards, or straightened --"tombstoning" represents acute transmural injury persistent ST elevation after acute MI suggests ventricular aneurysm ST elevation may also be seen as a manifestation of Prinzmetals (variant) angina--> coronary artery spasm
30
how does acute pericarditis ST elevation look on ECG
conCAVE upwards in MOST leads except aVR NO reciprocal ST segment depression (except in aVR) unlike early repolarization, T waves are usually low amplitude, and heart rate is usually increased may see PR segment depression, a manifestation of atrial injury
31
how does LVH ST elevation look on ECG
in right precordial leads with large S waves
32
how does LBBB St elevation look on ECG
in right precordial leads with large S waves
33
how does hypothermia ST elevation look on ECG
prominent J waves or Osborne waves
34
what is the ddx for ST segment depression
1. normal variants or artifacts - -ie wandering baseline due to poor electrode to skin contact, physiologic J juntional depression with sinus tachy, hyperventilation induced 2. ischemic heart disease 3. NSTEMI 4. reciprocal changes in acute STEMI 5. non ischemic causes
35
how does ischemic heart disease ST depression look on ECG
represents subendocardial ischemia i.e exercise induced or from angina attack ST segment depression is often described as "horizontal," "upsloping" or "downsloping" --> "upsloping" ST depression is not an ischemic abnormality
36
where might you get ST depression in an acute inferior MI
leads I and aVL
37
what are some non ischemic causes of ST depression
RVH or LVH (right or left precordial leads) digoxin effect on ECG hypokalemia secondary ST segment changes with IV conduction abnormalities
38
what blood work do you order in suspected MI
routine BW--CBC, lytes, Cr, urea and troponin q6H x2 consider CK imaging is CXR to r/o other causes and look for complications
39
what is the immediate management of MI
ABCs ``` initial therapy: MONA BE morphine oxygen nitro ASA Beta blocker (if can tolerate) Enoxaparin/LMWH (if normal Cr) ```
40
how do you assess ABCs in MI patient
A--airway patent? patient talking? thyro-mental distance, malampati score, GCS score B--oxygen, auscultate for air entry, r/o pneumothorax, Killip score for pulmonary edema, CXR C--pulses bilaterally, IV access, fluid status, JVP, cardiac monitoring
41
what is the pneumonic for initial MI management
MONA BE ``` Morphine oxygen nitro ASA beta bockers enoxaparin/heparin --also clopidogrel ```
42
when are beta blockers contraindicated in MI management
CHF bradycardia hypotension
43
why do we use beta blockers in MI management
prevents v fib and cardiac rupture which leads to reduced mortality
44
what do we use to reduce pain in acute MI
nitroglycerin S/L q5min x 3 unless hypotensive morphine/fentanyl IV nitro--> improves coronary blood flow reduces afterload if CHF/HTN and relieves spasm
45
dose of ASA to give in acute MI
325 mg to chew
46
why do we use LMWH in acute MI
decreases incidence of early reocclusion after thrombolytic
47
other than the MONA BE meds, what other meds should you consider in acute MI management
clopidogrel | ACEi--> especially if anterior infarct without hypotension as it decreases afterload and limit ventricular remodeling
48
what should you give to a patient with RV infarct and hypotension
fluid or inotropes (dopamine, dobutamine) and monitor CVP with central line
49
how do you decide between thrombolytics and immediate angioplasty for open occluded artery
if facilities are available or there is a contraindication to thrombolytics then do immediate angioplasty thrombolytics preserve myocardium and function, reduce mortality and decreases incidence of complications
50
how do you manage an open occluded artery in MI
reperfusion therapy with either primary percutaneous intervention (PCI) or, if less than 12 hours has elapsed from onset of symptoms, do fibrinolysis
51
how do you select patients from thrombolysis
less than 6 hours from pain onset: ST segment elevation in 2 contiguous leads
52
what are contraindications from thrombolytics
``` aortic dissection acute pericarditis less than 2 weeks from major surgery or trauma ICH or trauma BP above 200/120 active internal bleeding prolonged or traumatic CPD prolierative retinopathy or other hemorrhagic ophtho conditions ``` *always weigh ischemic risks (TIMI score) with bleeding risk
53
after acute initial management for MI what do you do
transfer to CCU or ICU angiogram if not done earlier - -ECHO - -stress test for stable angina follow troponin, CK, check glycemic and lipid profiles cardiac lifestyle teachings especially smoking cessation, cardiac rehab, control HTN, DM, DLD
54
order of administration of meds and interventions in acute MI
1. oxygen by mask or nasal cannular 2. ASA 160-325 mg chewable 3. nitroglycerin 0.4 mg SL (can repeat if well tolerated) - -can also give nitroglycerin 5-10ug/min IV if chest pain recurs or persists 3. 5. Metoprolol 5 mg IV q5min x3 4. morphine 2-4 mg IV bolus - -increments of 2-4 mg repeated every 5-10 minutes until the pain is relieved or no more is tolerated
55
in which patients should nitrates be avoided
RV infarct patient is on viagra or another PDE5 inhibitor hypotension
56
clopidogrel loading dose
300-600 mg followed by 75 mg daily maintenance dose
57
management of STEMI per edmonton manual
``` O2 morphine ASA Plavix LMWH beta blocker ACEi nitroglycerin high dose statin ``` revascularize within 12h of onset of chest pain with PCI thrombolyse if PCI unavailable for more than 2 hours

LMCC Part II (52 decks)

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