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Emergency Medicine > Lecture 5: Chest Pain Readings > Flashcards

Lecture 5: Chest Pain Readings Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Classic presentation of cardiac chest pain

A

Retrosternal in the left anterior chest with crushing, tightness, squeezing, or pressure brought on by exertion but relieved with rest

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2
Q

What demographics are more likely to have atypical presentations of cardiac chest pain?

A
  1. Women
  2. Minorities
  3. Diabetics
  4. Elderly
  5. Psychiatric disease
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3
Q

How do patients with ACS tend to present on physical?

A

Normal.

Vitals are primarily abnormal.

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4
Q

What EKG findings suggest ACS?

A
  • New STE
  • Q waves
  • New LBBB
  • T-wave inversions or normalizations
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5
Q

What underlying condition can elevate cTn?

A

Renal failure

This is why we want serial trops

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6
Q

If we suspect Pulmonary embolism, what criterias can help us?

A
  • PERC (PE Rule-out Criteria)
  • Wells Score
  • Revised Geneva Scores
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7
Q

Classic description of aortic dissection

A

Sudden onset of severe, tearing pain that radiates to the intrascapular area of the back.

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8
Q

RFs for aortic dissection

A
  • Male
  • > 50
  • Uncontrolled HTN
  • Cocaine
  • Atherosclerosis
  • Marfans/EDS
  • Valve replacement
  • Pregnant
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9
Q

Classic spontaneous pneumothorax case

A
  • Sudden onset, sharp, pleuritic chest pain with dyspnea
  • Tall, slender male who smokes, COPD, and asthma
  • Decreased breath sounds on affected side
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10
Q

Classic acute pericarditis case

A
  • Sharp, severe, constant, retrosternal pain radiating to back, neck or jaw
  • Pain worse when supine but relieved sitting forward
  • Pericardial friction rub
  • PR depression, diffuse STE or T-wave inversions
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11
Q

What are the MSK causes of chest pain?

A
  • Costcochondritis
  • Xiphoidynia
  • Precordial catch syndrome
  • Intercostal strain 2/2 coughing, pectoralis muscle strain
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12
Q

What are the GI causes of chest pain?

A
  • GERD
  • Dyspepsia
  • Esophageal motility disorder

Need imaging/diagnostics to differentiate

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13
Q

What is the first medication given to patients at risk for AMI in the ED?

A

Aspirin

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14
Q

What criteria helps with risk stratification of AMI?

A
  • TIMI (Thrombosis in MI)
  • Global Registry of ACE
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15
Q

What falls under ACS?

A
  • STEMI
  • NSTEMI
  • Unstable Angina
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16
Q

RFs for CAD

A
  • Older Male
  • FHx
  • Smoking
  • HTN
  • Hypercholesterolemia
  • DM
  • Cocaine
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17
Q

If we suspect ACS, what is the workup to order?

A
  • EKG
  • Serum cTn
  • CXR
  • CBC
  • Lytes
  • PT/PTT
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18
Q

How is unstable angina dx?

A
  • Lack of STEMI or NSTEMI
  • Began in last 2 months
  • Increased S/S compared to existing angina
  • Existing angina but it also occurs at rest
  • Evidence of CAD
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19
Q

STEMI goals

A
  1. Systemic thrombolytic within 30min of arrival
  2. PCI within 90min (PREFERRED)
  3. If you can get PCI within 120 minutes, you go for PCI, even if systemic thrombolytics are available.
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20
Q

MONA for ACS

A
  • Morphine
  • O2 > 95%
  • NTG
  • Aspirin chewable 160-324 mg
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21
Q

When is clopidogrel indicated for ACS?

A
  • High risk STEMI or NSTEMI.
  • Used as adjunct to ASA, but can be used alone if allergy to ASA.
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22
Q

When to use LWMH/UFH for ACS?

A

Unstable angina or NSTEMI

UFH preferred for CABG.

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23
Q

When is fondaparinux used in ACS?

A

Replacement of UFH in unstable angina or NSTEMI.

Also usable in STEMI without renal impairment that used streptokinase.

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24
Q

When can fibrinolytics be used for STEMI?

A
  1. NO timely access to PCI
  2. Time to treat < 6-12 hrs of onset
  3. EKG showing 1mm or greater STE in 2+ contiguous leads
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25
Q

If a patient begins significant bleeding post systemic thrombolytics, what do we do?

A
  • Crystalloid + PRBCs
  • Cryoprecipitate + FFP to reverse
  • Last resort: TXA or aminocaproic acid
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26
Q

What anti-ischemic drug should be given within 24h of ACS?

A

BB

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27
Q

What is meant by low-probability ACS?

A
  • Chest pain suggest possible coronary ischemia
  • Lack of STE or depression
  • Initial cardiac biomarkers are not elevated
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28
Q

How does low-risk chest pain present?

A

Pleuritic, positional, sharp, stabbing or reproducible

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29
Q

What falls under the primary evaluation for ACS?

A
  • H&P
  • EKG
  • Cardiac biomarker (initial)
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30
Q

What are the categories to classify people into post primary evaluation of ACS?

A
  1. Acute MI
  2. Probable acute ischemia (high risk for MACE)
  3. Possible acute ischemia (intermediate risk for MACE)
  4. Possible acute ischemia (low risk for MACE)
  5. Definitely not ischemia
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31
Q

What is the primary goal of a secondary evaluation for ACS?

A
  • Exclude MI
  • Exclude unstable angina
32
Q

Who is noninvasive stress testing recommended to in terms of risk?

A

Low to intermediate risk patients

33
Q

Initial management of suspected ACS in the ED

A
  1. MONA (morphine, oxygen, ntg, asa)
  2. Metoprolol PO
  3. DAPT vs heparin vs enoxaparin
34
Q

MC cardiomyopathy

A

DCM

Usually idiopathic

35
Q

Clinical features of DCM

A
  • S/S of acute HF due to systolic pump dysfunction
  • DOE, Orthopnea, PND
  • Rales, Dependent edema, hepatomegaly, holosystolic murmur, sometimes chest pain
36
Q

Dx of DCM

A

Echocardiogram showing

  • decreased EF
  • ventricular enlargement
  • increased systolic and diastolic volumes

A big ventricle

37
Q

Chronic therapy for DCM

A
  • Diuretics
  • Digoxin
  • ACEi
  • BBs

Edema is a common symptom

38
Q

If ventricular ectopy occurs due to DCM, what drug will treat it?

A

Amiodarone

39
Q

Clinical features of myocarditis

A
  • Myalgias, HA, rigors, fever, tachycardia
  • Chest pain with coexisting pericarditis is common
  • Pericardial friction rub
  • Severe: S/S of HF

Myocarditis is a common cause of DCM

40
Q

Management of Myocarditis

A
  • Supportive care + admission
  • ABX if bacterial is suspected
  • Monitor for HF symptoms
41
Q

What is an LVAD?

A

Left ventricular assist device, which is a pump that transfers blood from the apex of the LV to proximal aorta.

42
Q

Clinical features of an LVAD?

A
  • Continuous pumps may cause abnormal palpable pulses
  • Discernible QRS complexes
  • Whirr like heart sounds from LVAD pump
43
Q

What are the common complications of LVADs?

A
  • Infection (ABX)
  • Anemia (transfusions)
  • Bleeding
  • Thromboembolism (heparin)
44
Q

What is HCM?

A
  • Hypertrophic cardiomyopathy, characterized by asymmetric LVH or RVH, resulting in decreased compliance of LV, impaired diastolic function and filling
  • Normal EF, normal CO
  • Often hereditary
45
Q

Clinical Features of HCM

A
  • Worsens with age
  • DOE is MC symptom, followed by angina, palps, and syncope
  • S4 + systolic ejection murmur at LLSB or apex without radiation
  • Murmur is enhanced by valsalva/standing
  • Murmur is decreased by squatting and passive leg elevation

Squatting increases LV filling

LLSB = lower left sternal border

46
Q

EKG findings suggestive of HCM

A
  • LVH
  • LAE
  • Deep S waves with large Q waves

Nonspecific

47
Q

Best diagnostic for HCM

A

Echocardiogram showing disproportionate septal hypertrophy

48
Q

Daily tx of HCM

A

atenolol 25-50 mg daily

49
Q

What is RCM? Common causes?

A
  • Restrictive cardiomypathy, characterized by restricted ventricular filling with diastolic dysfunction
  • Etiologies: Sarcoidosis, scleroderma, amyloidosis, idiopathic
50
Q

Clinical features of RCM

A
  • Dyspnea
  • Orthopnea
  • Pedal edema
  • Angina is uncommon in RCM
  • S3/S4, rales, JVD, kussmaul’s sign, hepatomegaly, pedal edema, or ascites
51
Q

What is the primary thing you need to distinguish RCM from?

A

Constrictive pericarditis, because it is treatable via surgery, while RCM cannot.

52
Q

Main pharm tx for RCM

A
  • Diuretics
  • ACEi
  • Underlying cause (steroids for sarcoidosis or chelation of hemochromatosis)

Edema is a common symptom.

53
Q

Etiologies for acute pericarditis

A
  • Infection
  • Malignancy
  • Drugs
  • Radiation
  • CT diseases
  • Uremia
  • Myxedema
  • Dressler’s (post-MI syndrome)
54
Q

Clinical features of acute pericarditis

A
  • Sharp or stabbing precordial/restrosternal angina radiating
  • Pain worse supine, alleviated by sitting up and leaning forward
  • Radiation to left trapezial ridge is distinct
  • Intermittent friction rub at LLSB
55
Q

How does EKG stage 1 of acute pericarditis present?

A
  • Diffuse STE, esp in I, V5, V6
  • PR depression in 2, aVF, V4-6
56
Q

How does EKG stage 2 of pericarditis present?

A
  • ST segments normalize
  • T-wave amplitude decrease
57
Q

How does EKG stage 3 of pericarditis present?

A
  • T wave inversion in leads that used to have STE
58
Q

How does EKG stage 4 of pericarditis present?

A

Normal EKG

59
Q

What EKG finding is suggestive of acute pericarditis over early repol abnormalities?

A

ST segment/T-wave amplitude ratio > 0.25 in I, V5, V6

60
Q

Management of acute pericarditis

A
  • Viral/idiopathic = NSAIDs like ibuprofen Q6h outpatient
  • Colchicine BID may prevent recurrence
  • If associated myocarditis, admit
61
Q

What autoimmune condition can cause cardiac tamponade?

A

SLE

62
Q

Clinical features of nontraumatic cardiac tamponade

A
  • Mild to severe shock
  • MC: Dyspnea
  • Tachycardia, Low SBP, narrow PP
  • Pulsus paradoxus
  • JVD
  • Distant heart sounds
  • RUQ pain (if hepatomegaly)

Beck’s triad is JVD, hypotension, distant heart sounds

63
Q

EKG findings associated with cardiac tamponade

A
  • Low voltage QRS
  • STE with PR depression
  • Electrical alternans (classic but uncommon)
64
Q

Best test for cardiac tamponade

A

Echo showing large pericardial effusion with RA or RV diastolic collapse

65
Q

Management of Cardiac tamponade

A
  • Resuscitatation
  • IV of 500-1000 mL NS to temporarily improve hemodynamics
  • Pericardiocentesis
66
Q

Clinical features of constrictive pericarditis

A
  • Similar presentation to HF and RCM
  • DOE, pedal edema, hepatomegaly, ascites
  • Kussmaul’s sign (inspiratory neck vein distention)
  • CT/MRI/Doppler Echo is best for Dx
67
Q

What features of an AAA are likely to require surgery?

A
  • > = 5.0cm
  • Symptomatic
68
Q

Clinical features of a ruptured AAA

A
  • Older male smoker with atherosclerosis presenting with sudden severe back or abd pain, hypotension, and pulsatile abdominal mass
  • Retroperitoneal rupture may cause Cullen’s, Grey-Turner, or scrotal hematoma, but is generally rare.

Cullens = periumbilical
Gray cullens = bilateral flank

69
Q

What is the MC misdiagnosis of a AAA?

A

Renal colic :(

70
Q

Imaging for AAA

A
  • Bedside Abdominal U/S can find it and its diameter
  • CT can delineate its full details and associated rupture
71
Q

Management of a AAA

A
  • Vascular consult
  • Stabilize with goal SBP of 90
  • 3-5cm = refer, 5.0cm and higher = monitor closely
72
Q

Clinical features of aortic dissection

A
  • Blood between intimal and adventitial layers of aorta
  • Acute chest pain most severe at its onset and radiating to the back
  • Ascending = anterior chest pain most commonly
  • Descending = abdominal/back pain most commonly
  • Older than 50 with hx of HTN
73
Q

Stanford classification of Aortic Dissections

A
  • Type A for ascending aorta
  • Type B for descending aorta

A = ascending

74
Q

DeBakey classification of aortic dissections

A
  • Type 1: Involvement of both ascending and descending
  • Type 2: Ascending only
  • Type 3: Descending only
75
Q

What are the unique S/S that may suggest aortic dissection?

A
  • Compression of recurrent laryngeal nerve (Hoarse voice)
  • Compression of superior cervical sympathetic ganglion (Horner’s syndrome)
  • Aortic insufficiency
76
Q

Dx of Aortic dissection

A
  • CXR: abnormal aortic contour + mediastinal widening, tracheal deviation
  • CT w/ con can detect the false lumen + identify extent of dissection (IMAGING OF CHOICE)
  • TEE if you can get it
77
Q

Management of aortic dissection

A
  • Vascular consult
  • Manage HTN via esmolol or labetalol
  • Goal HR: 60-70
  • Goal SBP: 100-120
  • Consider nitroprusside or nicardipine once inotropic blockage is achieved but SBP still > 120.

Emergency Medicine (29 decks)

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