clinical approach to chest pain

Question 1

what is the most common cause of non-emergent chest pain

Answer 1

musculoskeletal pain (36%)
while cardiac is only 16%

Question 2

what are the 4 killer chest pains

Answer 2

Acute Coronary Syndromes
Pulmonary Embolism
Aortic Dissection
Tension Pneumothorax (least common)

Question 3

what are common causes of cardiac chest pain

Answer 3

Angina
Myocardial infarction
Aortic valve disease
Hypertrophic or congestive cardiomyopathy
Aortic dissection
Pericarditis
Mitral valve prolapse

Question 4

list areas that angina present

Answer 4

most common: the substernal area

next most common: jaw, epigastrium and inner aspect of the left arm

3rd most common: the neck, right shoulder and inner right arm

Question 5

Physical Signs in Acute CAD

Answer 5

Pallor
Sweating
Anxiety
Tachycardia
Rise in blood pressure (all of the above are due to sympathetic stimulation due to pain)
S4 gallop
Mitral regurgitation murmur (w/ inferior wall ischemia or infarct)
Paradoxically split S2 (LBBB)
Pulsus alternans (indicate impending LV failure and cardiogenic shock)

Question 6

Acute Coronary Syndrome

Answer 6

Unstable Angina
NSTEMI (non ST-seg elevation MI)
STEMI (ST-segment elevation MI)

Question 7

method of how coronary thrombosis is caused

Answer 7

• plaque equilibrates between vulnerable and non-vulnerable plaques.
• when it is vulnerable physical or mental stress can trigger rupture.
• rupture triggers intracoronary thrombosis which can be occlusive if coagulability or vasoconstriction increase.
• this causes symptoms of angina, unstable angina, myocardial infarction, or even sudden death depending on the size.

Question 8

in an acute MI can an EKG be normal?

Answer 8

yes - about 10% of the time it will be, especially with an occlusion of the circumflex artery

Question 9

signs of a MI on an EKG

Answer 9

elevated ST segments, inverted T waves, the development of Q waves within 12 hours.

Question 10

what other syndromes can look like an MI on an EKG

Answer 10

Pericarditis, J-Point elevation, W-P-W Syndrome

Question 11

how can you tell the difference between a NSTEMI and unstable angina

Answer 11

EKG will look the same so you need to look at the biomarkers

Question 12

general rule for ST elevation vs depression

Answer 12

ST depression = ischemia,

ST elevation = infarction.

Question 13

reciprocal changes on an EKG

Answer 13

is an electrical phenomena - go away when an ST segment elevation goes away

If the ST depression goes away in 24 hours then it is attributed to electrical reciprocity due to the myocardial infarction. If it stays, it may indicate ischemia.

Question 14

Troponin I & T

Answer 14

Specific for cardiac injury
Most sensitive when you take the diagnostic window out to 24 hours
It is not an earlier marker!
The majority of Troponins are not elevated in the first few hours
It remains elevated for many days!
When elevated is a marker for increased risk with non-ST elevation Acute Coronary Syndrome

Question 15

Stable angina

Answer 15

Angina that occurs at a predictable amount of energy expenditure or emotion

goes away with rest or nitroglycerin

Question 16

true or false pain occurs when ischemia begins

Answer 16

False: pain does not occur until 30 seconds after the occlusion. This is after there have been EKG changes present

Question 17

grades of Angina Pectoris

Answer 17

I- only w/ strenuous activity
II- slight limitations on normal activities (fast walking/stairs)
III- limitations to ordinary activity- occurs when walking 2 blocks or 1 flight of stairs)
IV- inability to carry on physical activity w/o pain, may even ocurr at rest

Question 18

when should a stress test be used

Answer 18

• if the history is indeterminate for cardiac chest pain vs. musculoskeletal pain

may also be used:
Estimating progress and severity of disease
Evaluation of therapy
Screening for latent coronary disease (not common)
Evaluation of arrhythmias

Question 19

Bruce protocol

Answer 19

5 stages of a stress test increasing speed and incline to increase the HR and BP of the patient and monitor symptoms, signs and the ECG to look for coronary insufficiency.

Question 20

normal stress ECG

Answer 20

upsloping ST-segment

Question 21

abnormal stress ECG changes

Answer 21

The ST position 2 mm from the end of the QRS (or J point) is observed. 1mm or greater depression with a horizontal or downward slope is (+) for ischemia.

Question 22

you can increase the sensitivity of a stress test by

Answer 22

adding imaging - either echo or nuclear

Question 23

Pericarditis – EKG

Answer 23

The EKG in pericarditis may show diffuse (every lead) ST elevation of lumen to possibly 2mm. This, if present, is diagnostic. Not all pericarditis has a positive ECG. Myocardial infarction ST elevation is usually greater or localized. (For example: ST elevation is 23F leads only).

also fever and chest pain is better when sitting up

Question 24

3 major symptoms of aortic stenosis

Answer 24

CHF – 2 year survival
Syncope – 3 year
Angina – 5 year

Question 25

GI causes of chest pain

Answer 25

GERD
diffuse esophageal spasm (present like angina and is relieved by nitro)
cholecystitis and cholelithiasis

Question 26

pulmonary causes of chest pain

Answer 26

pulmonary hypertension
pneumothorax
pulmonary embolism

Question 27

neuromuscular causes of chest pain

Answer 27

Herpes zoster (shingles)
Cervical arthritis
Chest wall pain and tenderness

Question 28

describe the pain associated with an aortic dissection

Answer 28

Cataclysmic onset - (sudden and severe)
Most severe at onset, “tearing”, “stabbing”
Tendency to migrate (may tell you were the tear is)
Anterior thorax (proximal); interscapular (distal)

Question 29

signs of an aortic dissection

Answer 29

Pulse deficit (proximal), aortic regurgitation (proximal)
Neurological deficits (proximal) – CVA, paraparesis, peripheral neuropathy, vasovagal
(EKG is often normal)

Question 30

who is more likely to have an aortic dissection

Answer 30

Men 2x, 50 – 60 year old, proximal 2x

Predisposing factors:
HTN, pregnancy, congenital (bicuspid aortic valve, coarctation, Marfan, Ehlers-Danlos)

Question 31

sign of a pulmonary embolism

Answer 31

positive D-dimer test

Question 32

Pneumothorax

Answer 32

Air in the pleural space
Spontaneous
Secondary
Tension pneumothorax can be quickly fatal