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Medicine Clerkship > Learning Objectives - Chest Pain > Flashcards

Learning Objectives - Chest Pain Flashcards

1
Q

DDx - acute chest pain (GI)

A
  1. Esophageal disease (GERD, esopahgitis, dysmotility)
  2. Biliary disease (cholecystitis, cholangitis)
  3. PUD
  4. Pancreatitis
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2
Q

Symptoms, signs, and other abnormalities seen in esophageal disease?

A

Burning substernal chest pain after meals, worse with lying down/bending over, better with antacids, +/- nausea

No reliable signs (mild epigastric discomfort an palpation)

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3
Q

Symptoms, signs, and other abnormalities seen in biliary disease?

A

RUQ pain

Murphy’s sign, +/- jaundice

Abnormal LFTs

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4
Q

Symptoms, signs, and other abnormalities seen in PUD?

A

Gnawing midepigastric pain

Epigastric tenderness

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5
Q

Symptoms, signs, and other abnormalities seen in pancreatitis?

A

Moderate to severe mid-epigastric pain with radiation to the back

Epigastric tenderness

Elevated amylase and lipase

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6
Q

DDx - acute chest pain (pulmonary)

A
  1. Pneumonia
  2. Spontaneous PT
  3. Pleurisy
  4. PE
  5. Pulmonary HTN/cor pulmonale
  6. Pleural effusion
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7
Q

Symptoms, signs, and other abnormalities seen in pneumonia?

A

Productive cough, fever

Crackles, egophony, whispered pectoriloquy

Infiltrate on CXR, elevated WBC

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8
Q

Symptoms, signs, and other abnormalities seen in pneumothorax?

A

Acute pleuritic chest pain and dyspnea

Decreased breath sounds in affected hemithorax, hyperresonance to percussion, possible tachycardia, distended neck veins, hypotension

Abnormal CXR

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9
Q

Symptoms, signs, and other abnormalities seen in pleurisy?

A

Pleuritic chest pain, dyspnea, +/- viral syndrome

Pleural friction rub, small tidal volume breathing

CXR possible pleural effusion

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10
Q

Symptoms, signs, and other abnormalities seen in PE/DVT?

A

Sharp pleuritic chest pain with associated dyspnea

Unilateral leg swelling/and or tenderness, tachycardia, hypoxemia

Abnormal CT, V/Q scan, elevated D-Dimer, abnormal EKG (sinus tachycardia, non-specific ST/T-wave changes, S1Q3T3)

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11
Q

DDx - acute chest pain (MSK)?

A
  1. Costochondritis
  2. Rib fracture
  3. Myofascial pain syndroems
  4. Muscular strain
  5. Herpes zoster
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12
Q

Symptoms, signs, and other abnormalities seen in costochondritis?

A

Sharp anterior chest pain at the costochondral and costosternal junctions; possibly pleuritic

Tenderness to palpation over the chest wall

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13
Q

Symptoms, signs, and other abnormalities seen in rib fracture?

A

Pleuritic chest pain, worse with movement, associated trauma

Tender over affected rib

Fracutre on CXR

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14
Q

Symptoms, signs, and other abnormalities seen in myofascial pain syndromes?

A

Widespread pain, often with trigger points, often associated with depression/sleep disorder

Tender over trigger points

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15
Q

Symptoms, signs, and other abnormalities seen in muscular strain?

A

Chest pain after excessive exercise or cough

Possible chest wall tenderness

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16
Q

Symptoms, signs, and other abnormalities seen in herpes zoster?

A

Pain and possible itching in dermatomal distribution

Initially absent rash, then characterstic

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17
Q

DDx - acute chest pain (psychogenic)?

A
  1. Panic disorder
  2. Hyperventilation
  3. Somatofrm disorder
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18
Q

Symptoms, signs, and other abnormalities seen in panic disorders?

A

Sudden intense anxiety, often associated with palpitations and dyspnea, not typically brought on by exertion

Tachycardia, tachypnea

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19
Q

Symptoms, signs, and other abnormalities seen in hyperventilation?

A

Dyspnea, lightheadedness, often associated with anxiety

Tachypnea

ABG with low PCO2

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20
Q

DDx - acute chest pain (CV)?

A
  1. Stable angina
  2. Unstable angina
  3. Acute MI (NSTEMI, STEMI)
  4. Atypical/variant angina (coronary vasospasm/Prinzmetal angina)
  5. Cocaine-induced
  6. Percarditis
  7. Myocarditis
  8. Aortic dissection
  9. Valvular heart disease (aorta stenosis - anginal pain, mitral valve prolapse - atypical chest pain)
  10. Arrhythmia
  11. Heart failure
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21
Q

EKG and Echo findings of pericarditis?

A

Difffuse concave-upward ST segment elevations and a depressed PR segment

Pericardial effusion

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22
Q

Symptoms, signs, and other abnormalities seen in aortic dissection?

A

Acute, sudden onset of severe crushing or tearing pain in the center of the chest radiating to the back

Pulse and BP differential from side to side indicating significant peripheral artery obstruction, aortic insufficiency (diastolic heart murmur)

CXR - widened mediastinum

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23
Q

3 criteria for typical angina?

A
  1. Substernal chest discomfort with a characteristic duration and features
  2. Exertional in nature
  3. Relief with rest or nitroglycerin
24
Q

Features of atypical angina?

A

DM, F, elderly

Dyspnea, fatigue, nausea, abdominal discomfort, syncope

25
Q

What causes angina?

A

Myocardial oxygen demand exceeds supply

26
Q

Stable angina?

A

Stable: predictable pattern of chest discomfort that usually occurs with exertion or extreme emotion, relieved with rest or nitro in 5-10 min or less

27
Q

Unstable angina?

A

Chest pain at rest
Chest pain with less exertion
New onset (within 4-6 weeks)
Worsening in severity, frequency, duration

No response to nitro

28
Q

Symptoms, signs, and other abnormalities seen in non-ischemic cardiomyopathy?

A

Usually not chest pain; more often dyspnea or other CHF symptoms/signs

CXR - enlarged heart

Labs - elevated BNP

29
Q

What is syndrome X?

A

Typical exertional angina-like chest pain but with normal coronary arteries (normal angiogram)

Thought to be microvascular dysfunction

30
Q

Cause of unstable angina?

A

O2 supply decreases secondary to reduced resting coronary flow, indicates stenosis that has enlarged via thrombosis, hemorrhage, or plaque rupture

31
Q

Cause of acute MI?

A

Unstable plaque with occlusive coronary artery throbosis and myocardial necrosis

32
Q

What differentiates NSTEMI from unstable angina?

A

+Troponin in NSTEMI

33
Q

Risk factors for CV disease?

A 
Age (M>45*, F>55)
Male*
Family history of sudden death or premature CAD (M<55, F<65)
Smoking*
Dyslipidemia*
DM* (worst risk factor)
HTN*
Obesity
Sedentary life
Hx PVD, CVD
Estrogen use
Chronic inflammation
*Traditional risk factors
34
Q

Primary prevention of CVD?

A 
Avoid tobacco
Aggressively control DM
BP and cholesterol in normal range
Regular exercise
USPSTF: aspirin at 55 for women, 45 for men
Diet
35
Q

Secondary prevention of CVD?

A

Avoidance of risk factors
More aggressive cholesterol lowering (LDL <100)/diabetic control
CCBs, ACEIs, BBs, ASA

36
Q

In a patient admitted for chest pain with suspicion of ACS, what should be done?

A
  1. EKG
    - If persistent ST elevation, STEMI -> reperfusion (immediate diagnostic coronary angiography/cath/pCI, preferred for STEMI)
    - If no abnormalities or ST depression/T wave inversion -> troponins
  2. Troponins positive -> high risk, presume NSTEMI, invasive treatment
  3. Troponins negative -> low risk, unstable angina -> non-invasive treatment

Medications:

  1. Aspirin (160-325 on arrival, 81 daily after that) - all patients suspected of ACS without contraindication (clopidogrel if allergy)
  2. Sublingual nitroglycerin, then IV infusion (if active pain) for symptoms
  3. PO metoprolol
  4. Statin - atorv 80
  5. O2 (may limit myocardial injury)
  6. Morphine (analgesia + venodilation -> decreased preload and O2 requirements)
  7. LMWH (especially enoxaparin) preferred over unfractionated heparin 9all patients with MI)
  8. Antiplatelet (abciximab or eptifabatide) - STEMI only
  9. Beta blocker
  10. Thrombolytics when PCI not performed in pts with acute STEMI (ateplase, best if given in first 6 ho

Mortality benefit: ASA, BB, ACEI/ARB

37
Q

Troponins are highly sensitive and specific for an MI within the last ___ (time).

A

24 hours

38
Q

MOA of aspirin in ACS?

A

Reduces MI risk in unstable angina
Reduces mortality in patients with MI

By preventing platelet aggregation through irreversible inhibition of COX and the consequent formation of thromboxane A2

39
Q

MOA of metoprolol in ACS?

A

Reduces myocardial oxygen demand by decreasing HR, BP, and contractility
Reduces infarct size and frequency of MI
Improves short- and long-term survival
Prolonged diastole may help augment myocardial perfusion

40
Q

Labs to order in evaluating chest pain?

A

CBC, BMP, troponin, TSH, lipids, ALT (for statins)

CXR, CT (if PE/dissection), EKG

41
Q

Risks of beta-blockers?

A

Hypotension, bradycardia, heart block

42
Q

MOA CCBs in ACS?

A

Dilate coronary arteries, increase coronary bloodflow, reduce myocardial oxygen consumption

43
Q

Risks of CCBs in ACS?

A

Constipation, HA, palpitations, dizziness, rash, drowsiness, flushing, nausea, edema

44
Q

MOA Nitrates?

A

Dilate systemic and coronary arteries, PRIMARILY VENODILATORS
Anti-ischemic effect due to reduced preload and decrease in myocardial oxygen demand

45
Q

Risks of nitrates?

A

HA, dizziness, nausea, flushing

46
Q

Massive contraindication to nitrates?

A

Right sided heart failure

47
Q

Indications for angiography with PCI?

A

NSTE ACS with recurrent symptoms of ischemia despite adequate medical therapy or who are at high risk

48
Q

Leads V1-V4 - ___ wall

A

Anterior

49
Q

Leads II, III, aVF - ___ wall

A

Inferior

50
Q

Leads I, aVL, V5, V6 - ___ wall

A

Lateral

51
Q

Inferior infarct typically associated with what type of occlusion?

A

Right coronary artery (90% of population with right-dominant)

Circumflex artery of the posterior descending (10% of population with atypical)

52
Q

Anterior infarct typically associated with what type of occlusion?

A

LAD

53
Q

Lateral infarct typically associated with what type of occlusion?

A

Circumflex

54
Q

Infarctions involving both the anterior and lateral portions of the heart most commonly represent a proximal occlusion of the ___

A

Left MCA

55
Q

Indications for stress test with high, intermediate, and low pre-test probability of CAD?

A

High - coronary angiogram
Intermediate - stress
Low - no stress test

56
Q

Cause of NSTEMI?

A

Thrombotic occlusion, mostly from plaque rupture

Medicine Clerkship (15 decks)

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