Evaluation of Chest Pain Flashcards
What angina symptom do older ppl. often present with?
dyspnea
who presents w/atypical chest pain?
women, diabetics & elderly
Chest pain: symptoms of 3 other life threatening causes
PE: pleuritic, a/w SOB, hemoptysis, risk factors
Aortic Dissection: ripping or tearing chest pain radiating to back/legs/throat, acute onset, a/w HTN, male, 50-70 years old
Cardiac tamponade: pain worse w/laying down, HYPOTENSION, MUFFLED HEART SOUNDS, JVD, pulsus paradoxus
Chest pain hx (memorize this list of 10)
Onset of pain (gradual or acute) Quality of pain (tearing, burning, stabbing, squeezing, pleuritic) Radiation (shoulder, jaw, back) Site (diffuse, localized) Course (waxing/waning, constant) Associated symptoms (SOB, N/V, hemoptysis, etc.) Risk factors Previous cardiac evaluation? Ever had this type of pain before? Social stressors?
Risk factors for CAD (15)
age gender (M>F) race tobacco use PVD HTN HLD Cancer Diabetes Family history Obesity/physical inactivity Stress Alcohol Illicit drugs Recent travel or surgery
Chest pain: physical exam (6 areas and what to examine there)
General: anxiety, diaphoretic, pale, cyanosis, Levine's sign Neck: JVD, carotid bruits Cardiac: rate, rhythm, murmurs Lungs: wheezing, rales, flail chest Abd: epigastric tenderness Ext: edema, Homan's sign Skin: lacerations, bruising, lesions
Initial dx workup of chest pain
CBC, CMP Cardiac enzymes (Troponin, CK-MB) D-Dimer BNP (if signs of CHF) Cardiac monitoring/telemetry CXR (PA+lateral) EKG (absence of ischemic changes-risk of AMI 4% w/hx CAD, 2% w/out hx CAD)
Stable angina characteristics
- oxygen supply/demand mismatch
- occurs with exercise
- relieved with rest and/or nitroglycerine
Unstable angina characteristics
- more severe, less predictable
- increasing severity/frequency/duration
- occurs at rest
- not relieved with rest and/or nitroglycerin
NSTEMI characterized by
non ST elevation MI
- NON-OCCLUSIVE thrombus
- ischemia with elevated cardiac enzymes
STEMI characterized by
ST elevation MI
- OCCLUSIVE thrombus
- transmural infarction
New LBBB are considered
MI until proven otherwise
Acute Coronary syndrome hx: Onset
gradual & worsens w/exertion, stress
Acute Coronary syndrome hx: time:
ANGINA/ISCHEMIA: <10 min, relieved w/rest
INFARCTION: prolonged & more sever, increasing frequency or constant
Acute Coronary syndrome: quality
discomfort (pressure, heaviness, tightness, fullness, squeezing)
Acute Coronary syndrome: location
substernal or left side chest with radiation to arm, neck, jaw, shoulder, back
NOT related to position or respiration
Most common signs/sxs of ischemic heart dz (8)
- chest pain, pressure, heaviness, tightness, squeezing
- N/V
- diaphoresis
- dyspnea
- palpitations, bradycardia, tachycardia, irregular
- syncope, dizziness
- fatigue
- fluid overload
What is the best test to identify acute myocardial infarction in ED?
12 lead ECG
12-lead ECG: use, goal
single best test to ID AMI in ED
goal: w/in 10 mins of presentation
- still low sensitivity (STEMI, NSTEMI, LBBB, paced rhythms)
- Useful in cardiac risk stratification (normal or nonspecific: 1-5% chance MMI, new ischemia increases the risk to 73%)
Troponins: pros, cons
more specific than CK-MB False positives w/: -sepsis -renal failure -PE (poor prognosis indicator) -subarachnoid hemorrhage
Creatine kinase (total & MB) onset, peak, duration
Onset: 3-12 hrs
Peak: 18-24 hrs
Duration: 36-48 hrs
Troponins: onset, peak, duration
Onset: 3-12 hrs
Peak: 18-24 hrs
Duration: up to 10 days
Myoglobin: onset, peak, duration
Onset: 1-4 hrs
Peak: 6-7 hrs
Duration: 24 hrs
Lactate Dehydrogenase: onset, peak, duration
Onset: 6-12 hrs
peak: 24-48 hrs
duration: 6-8 days
ACS lab studies (other than ECG & enzymes)
CBC, CMP
CWR: cardiomegaly, pulmonary edema
Echocardiography: LV wall thickness/LV enlargement, regional wall motion, valve function/dz, ejection fraction
Nuclear imaging: myocardial perfusion, localizes & quantifies myocardial damage (more expensive)
ACS treatment
IV access cardiac monitoring MONA Morphine Oxygen Nitroglycerin (SL, paste, drip) ASA 325 mg PO
- beta blocker (but NOT if pt is bradycardic)
- unfractionated heparin if indicated
others: ACE-I, CCB, clopidogrel
ACS-reperfusion
PCI, mechanical or pharmacologic:
- coronary angioplasty w/ or w/out stents; atherectomy
- fibrinolytic therapy: streptokinase, tPA, reteplase, tenectoplase
- antiplatelet therapy:glycoprotein IIb/IIA inhibitor (integrelin)
CABG (U) in ppl who can’t be stented
Coronary Artery Bypass Graft (CABG) description
surgical grafting of native blood vessels to bypass obstructed coronaries
CABG: where is it desirable, what is used
desirable for sites of critical flow (LAD)
Saphenous vein graft: superfluous vein from the leg, 50% patent after 10 years
Internal mammary artery graft:
superfluous branch of subclavian artery, remains patent more often than vein
90% patent after 10 years
Aortic Dissection: definition & presentation
severe, acute onset of tearing, sharp or ripping pain radiating to BACK, arms & throat
presentation: UNEQUAL PULSES/BP IN EXTREMITIES, aortic insufficiency murmur
sick appearing: shock, acute HF, CVA/neurologic abnormalities
Aortic dissection risk factors (6)
- HTN
- s syndrome or connective tissue d/s
- Biscupid aortic valve
- Cocaine use
- Prenancy
- Family history
Aortic Dissection Studies (4)
EKG: 15-30% ischemia or non-specific ST/T changes
CXR: 90% have abnormality
CT: CT angiography most widely available & enables prompt dx
TEE: aortic root
Aortic Dissection Treatment
- BP & HR control (nitroprusside, beta blockers)
- Emergent CT surgery consultation
- Reduce shearing forces & intensity of pulsatile HR
Pulmonary Embolism: description & presentation
acute onset chest pain OR painless dyspnea
Presentation: tachypnea, tachycardia, hypoxia, hemoptysis, SOB, fever, syncope, unilateral extremity edema suggestive of DVT
Risk factors for Pulmonary Embolism
Virchow’s triad:
Endothelial damage
Hypercoagulability
Stasis
prolonged immobilization/surgery, pregnancy, cancer
FH of hypercoagulable states
Well’s Criteria
suspected DVT=3 PE is #1 dx=3 HR>100=1.5 immobilized>3d or surgery<4 w/negative D-dimer, 2% chance of PE
Pulmonary Embolism: gold standard for dx
Pulmonary angiography
Pulmonary Embolism-Labs/Studies & expected results (7)
Labs: D-dimer
EKG: sinus tach, S1 Q3 T3 pattern
CXR: (U) normal, classic findings of Hampton’s hump & Westermark’s sign are rare
Gold Standard for dx: pulmonary angiography
Spiral CT w/IV contrast (CTA chest)
V/Q perfusion scan
LE Doppler U/S: used to evaluate for DVT
Pulmonary embolism-treatment
anticoagulation -unfractionated heparin vs. low molecular weight heparin -warfarin -fondaparinux ?thrombolytics or embolectomy ?hypercoaguable work-up
Pneumothorax presentation & physical exam
acute onset of severe sharp pleuritic chest pain, dyspnea
Phys Exam: respiratory distress, hypoxia, tracheal deviation, decreased or absent BS on affected side, hyperresonance to percussion
Pneumothorax ABG results
high Aa gradient
hypoxemia
Pneumothorax: CXR
may need lateral decubitus view to see air in pleural space
-tracheal deviation if under tension
Pneumothorax tx
high flow O2
+/- needle decompression
chest tube
serial CXRs
pericarditis presentation
constant, sub-sternal, pleuritic pain that
radiates to shoulder or back, worse with lying flat or deep inspiration
-described as “sharp” or stabbing
-relieved with leaning forward
Pericarditis ROS
+ fever, cough, dyspnea, abdominal pain or dysphagia
Pericarditis PE
+/- pericardial friction rub
Pericarditis causes
auto-immune, TB, neoplasm, purulent pericarditis
Pericarditis labs/studies & expected findings(3)
Labs: leukocytosis, ↑ESR, ↑troponin with NO elevation of CK
ECG: diffuse ST elevation, depression PR segment
CXR/Echo: pericardial fluid
Pericarditis Treatment
pain medication
anti-inflammatories, ASA, colchicine
+/-cardiac window/ pericardiocentesis
+/-pericardial biopsy (cytology, gram stain with culture, TB PCR)
+/- corticosteroids
Pericardial tamponade
fluid accumulation that leads to hemodynamic instability
Pericardial tamponade causes (6)
trauma, aortic dissection, pericarditis, malignancy, recent MI, TB
Pericardial Tamponade Presentation
Beck’s triad (low arterial blood pressure, distended neck veins, distant muffled heart sounds)
Pulsus paradoxus
Pericardial Tamponade-labs/studies
ECHO or CT MOST HELPFUL
CXR: enlarged cardiac silhouette
EKG: electrical alternans or low voltage QRS
Myocarditis definition
inflammation of heart muscle & frequently accompanied by pericarditis
Myocarditis presentation
- fever, tachycardia out of proportion with respect to temperature elevation, abnormal heart beat
- myalgia, HA, fever, rigors
- can progress to heart failure
Myocarditis risk factors
M>F, 4th decade, children
Myocarditis causes
viral (M) common: Coxsackie, Influenza, Parainfluenza, EBV, adenovirus, Hep B & C
bacterial: C. diptheriae, N. meningitides, M pneumonia, B-hemolytic strep
systemic inflammatory dzs: collagen-vascular dz, sarcoidosis, thyrotoxicosis
radiation
hypersensitivity reactions
Myocarditis: labs/studies (3)
Labs: leukocytosis, elevated cardiac enzymes, ESR/CPR
EKG: non-specific ST/T wave changes, ST elevation (if pericarditis), AV block, prolonged QT
echo to evaluate systolic function
Myocarditis tx
supportive
+/- antibiotics (depending on cause)
+/- immunosuppressant therapy
Mediastinitis presentation
- chest or abdominal pain, cough, hoarseness, dysphagia, history of forceful emesis
- ill-appearing, shock, fever
HAMMAN’S CRUNCH: crackling sound heart over mediastinum in patients with mediastinal emphysema
Mediastinitis: mortality risk?
HIGH
Mediastinits causes (3)
odontogenic infections
esophageal perforation
iatrogenic complications of cardiac surgery, GI or airway procedures
Mediastinitis: labs/studies
leukocytosis, blood cultures reveal a bacterial source
CXR: mediastinal or free peritoneal air, pleural effusion
CT: extra-esophageal air, mediastinal widening (confirmed with PO contrast), abscess
Mediastinitis treatment
broad spectrum antibiotics
CT surgery for debridement & repair
Pneumonia presentation
fever, cough, hypoxia
pleuritic CP
tachycardia, tachypnea
Pneumonia physical exam findings
rales on affected lobe
decreased breath sounds
Pneumonia-labs/studies/findings
labs: leukocytosis/leukopenia [leukopenia if infection is pretty advanced]
CXR: consolidation/inflitrate
Esophagitis presentation
(U) secondary to GERD
cannot be reliably discriminated from myocardial ischemia by history & exam alone
presentation: burning/gnawing chest pain in lower half of chest
Esophagitis tx
- GI cocktail (viscous lidocaine, Maalox, donnatol)
- H2 blocker, PPI
Esophageal Spasm: presentation & presentation
sudden onset of dull, tight or gripping substernal chest pain
(U) precipitated by hot/cold liquids or large food bolus
tx: sublingual nitroglycerin
Pleuritis: define, presentation, a/w
inflammation of pleura
“dx of exclusion”
presentation: sharp in nature, reproducible, worse w/inspiration “pleuritic”
a/w: PE, pericarditis, pneumonia
Costochondritis: definition
inflammation of costal cartilages and/or sternal articulations
Constochondritis: presentation
chest pain (sharp or dull), ↑with deep inspiration and palpation do CXR to rule out other causes
Costochondritis: treatment
anti-inflammatories
Herpetic Neuralgia: def & presentation
Herpes zoster (shingles)
presentation:
-clusters of vesicles & papules grouped on an erythematous base, vesicles initially clear then cloudy/purulent
-unilateral along dermatome without crossing midline
-shooting, sharp pain. Hyperesthesia with light palpation
