CHEST PAINS AND ANGINA Flashcards
Do acute coronary syndromes account for most emergency room visits for chest pain?
No, they account for only a small percentage (1%–11%) of visits.
What are the life-threatening causes of chest pain that should be quickly recognized?
ACS, aortic dissection, pneumothorax, pulmonary embolism, esophageal rupture.
What is angina?
Discomfort associated with myocardial ischemia or MI due to oxygen demand exceeding supply.
Who first described angina and when?
William Heberden in 1772.
What are the characteristics of typical angina?
- Substernal chest discomfort
- Provoked by exertion or emotional stress
- Relieved by rest or nitroglycerin
What is the difference between stable and unstable angina?
Stable occurs with increased demand; unstable occurs at rest or has a new onset.
What are the major risk factors for coronary artery disease?
- Age over 45 for men, over 55 for women
- Male gender
- Family history of premature CAD
- Hypercholesterolemia
- Hypertension
- Cigarette smoking
- Diabetes mellitus
What symptoms may accompany angina?
- Shortness of breath
- Diaphoresis
- Nausea
- Fatigue
- Radiating pains
What is the mortality rate increase associated with delayed diagnosis of aortic dissection?
Approximately 1% every hour from presentation to diagnosis and treatment.
What types of chest pain are less likely to indicate angina?
- Stabbing pain
- Pleuritic pain
- Positional pain
- Reproducible pain
True or False: The severity of chest pain is a strong predictor of angina.
False.
Fill in the blank: Angina can manifest as _______.
epigastric pain or discomfort.
What is the Levine sign?
When a patient clenches their fist over their chest while describing discomfort.
What duration of discomfort is typical for angina?
Minutes, not seconds or hours.
What describes the discomfort associated with myocardial ischemia or MI?
Angina.
What are the cardiovascular causes of chest pain?
- Stable angina
- Unstable angina
- Acute MI
- Aortic dissection
- Pericarditis
What are the pulmonary causes of chest pain?
- Pulmonary embolism
- Pneumonia
- Spontaneous pneumothorax
What are gastrointestinal causes of chest pain?
- Esophageal reflux
- Peptic ulcer
- Gallbladder disease
- Pancreatitis
What are the musculoskeletal causes of chest pain?
- Costochondritis
- Rib fractures
What is an ‘angina equivalent’?
Symptoms that manifest without classic chest discomfort, such as dyspnea.
What should be included in the differential diagnosis for chest pain?
- Cardiovascular
- Pulmonary
- Gastrointestinal
- Musculoskeletal
- Psychiatric
- Dermatologic
How do patients with aortic dissection typically describe their pain?
As tearing or ripping and radiating to the back
What is the Levine sign?
Occurs when the patient spontaneously clenches their fist over the chest while describing discomfort, indicating ischemic chest pain
What is the typical duration of stable anginal pain?
Approximately 2 to 10 minutes
What is the duration range for unstable anginal pain?
10 to 30 minutes
What activities can precipitate angina?
Exercise, mental stress, or anger
What typically relieves angina?
Sublingual nitroglycerin (SL NTG) or rest
What does partial or complete relief with SL NTG within 2 to 5 minutes indicate?
More likely to be experiencing angina
What are common associated symptoms that increase the likelihood of angina?
- Shortness of breath
- Diaphoresis
- Nausea
- Radiating pain
What ECG abnormalities increase the likelihood of angina or acute coronary syndrome (ACS)?
- ST-segment depressions
- ST-segment elevations
- T-wave inversions
What does an elevated troponin level indicate?
Significantly increases the likelihood of angina and coronary artery disease (CAD)
What physical exam findings suggest a cause other than angina?
- Rub on auscultation
- Difference in systolic blood pressure between arms
- Systolic murmur at the right upper sternal border
- Reproduction of pain with palpation
What is the classic ECG finding in a patient with a large pulmonary embolism (PE)?
S1Q3T3 pattern (prominent S wave in lead I, Q wave in lead III, T-wave inversion in lead III)
What is the initial workup for patients presenting with chest pain?
- ECG
- Chest X-ray
- Cardiac biomarkers (troponin, CK, CK-MB)
When should a stress test be obtained?
In patients with intermediate probability of having coronary artery disease (CAD)
What is Prinzmetal angina?
An uncommon type of angina caused by coronary vasospasm
What are common risk factors for Prinzmetal angina?
- Smoking
- Chronic alcohol use
- Cocaine use
When does Prinzmetal angina typically occur?
During rest, most commonly between midnight and 8 am
What is cardiac syndrome X?
A condition characterized by anginal symptoms despite normal coronary arteries on angiography
What is the primary treatment for Prinzmetal angina?
- Calcium channel blockers
- Nitrates
True or False: Women often present with typical anginal symptoms.
False
Fill in the blank: Pain that lasts continuously for a day or days is usually not ______.
angina
What is a characteristic feature of the pain associated with myocardial infarction (MI)?
Described as pressure
What finding on a chest X-ray can support the diagnosis of aortic dissection?
Widened mediastinum
What is Prinzmetal angina?
A type of angina caused by coronary artery spasm, leading to chest pain.
What are the first-line therapies for Prinzmetal angina?
Calcium channel blockers and nitrates.
What is cardiac syndrome X?
A condition where patients have exertional anginal symptoms but nonobstructive epicardial CAD.
What is another term for cardiac syndrome X?
Microvascular angina.
What is the recommended initial treatment for microvascular angina?
Beta-blockers.
What does an elevated troponin level indicate?
Possible myocardial necrosis but not definitive for acute coronary syndrome.
True or False: Troponin elevation alone confirms the diagnosis of acute coronary syndrome.
False.
What must accompany troponin elevation to support a diagnosis of acute coronary syndrome?
Angina or angina equivalent, ECG changes, and/or new wall motion abnormalities.
What is the typical pattern of troponin levels in myocardial infarction?
Rise-and-fall pattern.
List some conditions that can cause elevated troponin levels.
- Sepsis
- Hypotension
- Severe hypoxia
- Severe anemia
- Severe hypertension
- Tachyarrhythmias
- Cocaine use
What can cause troponin release during heart failure?
Myocardial strain.
What condition associated with troponin elevation is linked to worse prognosis?
Pulmonary embolism (PE).
What is myopericarditis?
Inflammation of the myocardium and pericardium causing elevated troponin levels.
What can aortic dissection involving the RCA lead to?
Secondary myocardial infarction.
How can chronic kidney disease affect troponin levels?
Troponins can be modestly chronically elevated.
True or False: Elevated troponin levels can occur in acute stroke.
True.
What is the risk associated with provocative testing for Prinzmetal angina?
Risk of coronary spasm refractory to NTG and other vasodilators.
What are the potential outcomes of coronary spasm during provocative testing?
- Prolonged ischemia
- Myocardial infarction (MI)
- Death
What types of testing may show abnormalities in cardiac syndrome X?
- ST-segment depressions
- Perfusion defects
- Wall motion abnormalities
What role does microvascular coronary artery constriction play in cardiac syndrome X?
It is believed to contribute to the condition in some patients.
What additional therapies can be considered for microvascular angina?
- Calcium channel blockers
- Nitrates
- Ranolazine
What is a common feature of elevated troponin levels in acutely ill, hospitalized patients?
Up to 45% are not due to coronary artery disease (CAD).
