Internal Medicine 02: 60-year-old woman with chest pain Flashcards
Cardiac Differential for CP
Variant Angina
Vasospastic cause of angina, often younger pt with few risk factors.
Accompanied by transient ST elevation on EKG.

Cocaine Induced Chest Pain
Chest pain after cocaine use from infarction or intense coronary spasm.
Patients may also have burn marks on lips and fingers from crack pipe.
Tox screen positive for cocaine.

Aortic Dissection
Crushing or tearing quality Murmur of aortic
pain in center of chest, radiates to back.
insufficiency may be present.
Widened mediastinum on CXR.
Valvular Heart Disease
Aortic stenosis can result in angina pain. Mitral prolapse patients often have atypical chest pain.
AS - systolic crescendo decrescendo murmur, MVP - midsystolic click with possible late systolic murmur.
Pericarditis
Severe retrosternal pain and pain alters with body positioning, often pleuritic or young patient
Pericardial friction rub.
Diffuse ST elevation on EKG, pericardial effusion on echocardiogram.
Non-ischemic Cardiomyopathy
Usually does not manifest as chest pain but rather dyspnea or other CHF symptoms.
Pulmonary edema, hepatic congestion, lower ext edema, jugular venous distension.
Enlarged heart on CXR, elevated b- type naturetic peptide.
Cardiac Syndrome X
Exertional angina-like chest pain, more common in women.
Usually normal EKG, abnormal exercise stress test with normal coronaries on angiogram and no evidence of coronary spasm.
Myocarditis
Similar to pericarditis but can also mimic ischemia.
May manifest as CHF.
Cardiac enzymes may be elevated.
Gastrointestinal Causes of Chest Pain
Esophageal Disease
Reflux disease can cause chest pain usually after meals, exacerbated by lying down or bending over, improved by antacids.
No reliable signs


Biliary Disease
Usually results in right upper quadrant pain.
Murphy’s sign - tender palpable gallbladder with a sudden halt of inspiration with palpation in the upper quadrant. Occasional jaundice
Abnormal liver function tests
Peptic Ulcer Disease Gnawing, midepigastric pain. Epigastric tenderness  Pancreatitis Moderate to severe midepigastric pain with radiation to the back. Epigastric tenderness Elevated amylase and lipase
Pulmonary Causes of CP
Pneumonia
Productive cough, fever
Crackles on lung exam, egophony, whispered pectoriloquy
Infiltrate on CXR, elevated WBC
Spontaneous Pneumothorax
Acute pleuritic chest pain and dyspnea
Decreased breath sounds in affected hemithorax, resonance to percussion, possible tachycardia distended neck veins and hypotension
Abnormal CXR
Pleurisy
Pleuritic chest pain, dyspnea, possible viral syndrome
Pleural friction rub heard with lung auscultation, small tidal volume breathing
Possible pleural effusion on CXR
Pulmonary Embolism
Pleuritic chest pain associated with dyspnea
Tachycardia, hypoxemia, possible right heart strain on EKG
Abnormal CT of chest, V/Q scan, elevated D-dimer
Musculoskeletal Causes of Chest Pain
Costochondritis
Sharp anterior chest pain occurring at costochondral and costosternal junctions. Possibly pleuritic
Tenderness to palpation over chest wall.

Rib Fracture
Pleuritic chest pain, worsened by movement, often associated trauma
Tender over affected rib
Rib fractures seen on X-ray

Myofascial Pain Syndromes
Widespread pain often with trigger points, often associated depression or sleep disorder
Tender over trigger points to palpation

Muscular Strain
Chest pain after excessive exercise or cough
Possible chest wall tenderness

Herpes zoster
Pain and possible itching in a dermatomal pattern
Rash absent initially then characteristic of zoster
Psychogenic Causes of Chest Pain
Panic Disorder
Sudden intense anxiety often associated with palpitations, dyspnea
Tachycardia, tachypnea,
Hyperventilation
Dyspnea, light-headedness, often associated with anxiety
Tachypnea
ABG shows low PCO2
Somatoform Disorders
Variety of somatic complaints, can include chest pain. Often history of psychiatric illness
Subjective complaints outnumber objective
angina 1
The Three Criteria for Typical Angina
- Substernal chest discomfort with a characteristic duration and features
- Exertional in nature
- Relief with rest or nitroglycerin
Atypical Angina
Patients who have diabetes, women, and the elderly are more likely to present with atypical features. Occasionally they will present with only weakness or shortness of breath on exertion. Those symptom are considered “anginal equivalents”.
Stable vs. Unstable Angina
Angina occurs when myocardial oxygen demand exceeds supply. When angina is thought to be present it is important to further characterize it as stable angina vs. unstable angina since these two syndromes are managed very differently.
»Stable angina pectoris is a predictable pattern of chest discomfort that usually occurs with exertion or extreme emotion. It is relieved by rest or nitroglycerin in less than 5-10 minutes.
»Unstable angina is a more serious condition characterized by chest pain that occurs at rest or with increasingly less exertion. New onset angina (within 4-6 weeks) and angina that has worsening severity, frequency or duration is also classified as unstable. Unstable angina is an acute coronary syndrome (along with non-ST segment elevation myocardial infarction and ST segment elevation myocardial infarction) and requires emergency care.
Risk Factors for Coronary Artery Disease and Atherosclerotic Cardiovascular Disease
Many risk factors have been independently associated with coronary artery disease. In addition to age > 55 in females or > 45 in males, male sex, family history of sudden death or premature CAD, smoking, dyslipidemia, diabetes mellitus, hypertension, and obesity; other risk factors for coronary artery disease are a sedentary lifestyle, a personal history of peripheral vascular or cerebrovascular disease, estrogen use and chronic inflammation.
Most of a person’s risk for CVD and for stroke (together called atherosclerotic cardiovascular disease, or ASCVD) can be determined by a limited set of major risk factors. Other minor risk factors are only helpful if they adjust a patient’s risk category from that determined by the major risk factors.
Of those listed above, only age, male sex, current smoking, dyslipidemia, diabetes, and hypertension are considered major traditional risk factors.
American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend assessing major ASCVD risk factors every 4 to 6 years in adults 20 to 79 years of age who are free from ASCVD.
Primary prevention of cardiovascular disease
(preventing disease in those without known disease) involves avoiding tobacco, aggressively controlling diabetes mellitus, keeping blood pressure and cholesterol in the normal range, and regular exercise. The USPSTF recommends initiating low-dose aspirin use for the primary prevention
of cardiovascular disease in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. For adults aged 60-69 years of age with a 10% or greater 10 year risk of CVD, the decision to use low dose aspirin for primary prevention must be individualized based on each patient’s life expectancy and longterm bleeding risk. For patients < 50 years or > 70 years, there is insufficient evidence to assess the balance of risks versus benefits of daily aspirin use for primary prevention.
Secondary prevention of cv dz
(preventing further disease in those with known disease) involves avoidance of risk factors, more aggressive cholesterol lowering, and diabetic control. Certain cv meds may be used as well, such as calcium channel blockers (CACBs) and (ACE) inhibitors.
Several studies have demonstrated that CACBs are effective in the treatment of stable angina. In 2007, the American College of Cardiology/American Heart Association(ACC/AHA) stated their preference of beta blockers (BB) over CACB based on BBs showing an improved survival rate in patients with CAD. CACBs should be considered when BBs are contraindicated. The ACC/AHA recommends patients with stable angina who have normal LV function be treated with ACE inhibitors, but there is conflicting evidence that they reduce exercise- induced angina. Aspirin prophylaxis is also an effective secondary prevention strategy.
Metabolic Syndrome Criteria
Abdominal obesity Waist circumference (men >102 cm (40 in), women >89 cm (35 in)
Triglycerides
> 150 mg/dL
1.70 mmol/L
HDL cholesterol
men < 40 mg/dL, women < 50 mg/dL
men <1.04 mmol/L, women <1.30 mmol/L
Blood pressure
> 130/85 mmHg
Fasting glucose
> 110 mg/dL
>6.1 mmol/L
Which Stress Test Should You Order?
Treadmill Exercise Stress Testing without additional imaging : Since the patient can exercise and the ECG is normal this is one option, however some have argued that women have higher rates of false positives and often cannot exercise to the extent needed for a diagnostic test.
Exercise Stress Testing with nuclear or echocardiographic imaging: Imaging increases the sensitivity and specificity of the test but increases cost too. Nuclear imaging utilizes technetium 99m sestamibi or thallium-201. Echocardiography can be technically difficult in the obese patient.
Pharmacologic Stress with imaging: This is an alternative if the patient cannot exercise to the degree needed to produce a diagnostic result. Options include dipyridamole or adenosine with nuclear imaging or dobutamine with echocardiography.
Angina Treatment
Beta blockers decrease myocardial oxygen consumption by slowing heart rate and decreasing blood pressure, and thus reduce angina.
Calcium channel blockers dilate coronary arteries and increase coronary blood flow while also decreasing myocardial oxygen consumption.
Nitrates dilate systemic and coronary arteries but are primarily venodilators. The anti-ischemic effect of nitrates is due to systemic venodilation that leads to reduced preload and a decrease in myocardial oxygen demand.
ecg
With an electrocardiogram, you can rule out an ST elevation MI, look for evidence of prior infarction (pathologic Q waves) and, occasionally, make other diagnoses such as pericarditis.
Evaluation of Suspected Angina
In addition to an ECG, studies indicated include:
CBC-anemia can contribute to ischemia by decreasing O2 carrying capacity
Electrolytes
can contribute to cardiac disease medications can alter electrolytes
BUN and Creatinine
useful for screening for kidney disease as this can contribute to heart disease medications can adversely affect kidney function
Thyroid Stimulating Hormone
screen for thyroid disease
hyperthyroidism increases oxygen demand of the heart while hypothyroidism adversely effects lipids
Fasting Lipid Panel
to further characterize cardiac risk
ALT
a baseline measurement of transaminase (ALT) levels should be performed before initiating statin therapy
