Lecture 8 Chest Pain/angina Flashcards
How many visits of chest pain are there per year
6.4 million
Cardiovascular assessment of chest pain
Onset
Provokes
Quality
Relievers
Severity
Timing
Associated symptoms
Pertinent negatives
T/F all chest pain is related to the heart
False
Acute coronary syndrome ( Stable angina)
ECG, troponin
Angina pain develops when there is increased demand in the setting of a stable atherosclerotic plaque. The vessel is unable to dilate enough to allow adequate blood flow to meet the myocardial demand
ECG: Normal
Troponin: Normal
Acute coronary syndrome ( unstable angina)
ECG
Troponins
The plaque ruptures and a thrombus forms around the ruptured plaque, causing partial occlusion of the vessel. Angina pain occurs at rest or progresses rapidly over a short period of time
ECG: Normal, inverted T waves, or ST depression
Troponin: Normal
Acute coronary syndrome (NSTEMI)
ECG
Troponin
During NSTEMI, the plaque ruptures and thrombus formation causes partial occlusion to the vessel that results in injury and infarct to the subendocardial myocardium
ECG: Normal, Inverted T waves, or ST depression
Troponin: Elelvated
Acute coronary syndrome ( STEMI)
ECG
Troponin
A STEMI is characterized by complete occlusion of the blood vessel lumen, resulting in transmural injury and infarct to the myocardium, which is reflected by ECG changes and a rise in troponins
ECG: Hyperacute T waves, or ST elevation
Troponin: Elevated
Evaluating Cardiac Chest pain (CP)
Components
Quality
Location
Duration
Associated symptoms
Provokes
Relievers
Evaluating cardiac Chest pain (Quality)
Squeezing, gripping, pressure, heavy
Discomfort rather than pain
Not tender to touch
Change with position
Evaluating cardiac CP ( Location)
Substernal or retro steal
Radiation: Neck, Jae, epigastrium, back, arms
Evaluating cardiac CP: stable coronary syndrome/ stable angina
Duration
Associated symptoms
Provokes
Relievers
Duration : usually 2-5 mins
Associated symptoms: lightheaded, fatigue, dyspnea, palpitations, nausea, diaphoresis
Provokes: usually predictable, 4E’s (exertion, emotional distress, extreme temps, eating)
Relievers: Rest or SL nitroglycerin
Clinical classification of CP
Cardiac
Possible cardiac
Non cardiac
Cardiac:
1. Sub-sternal with characteristic quality and duration
2.provoked by exertion or emotional stress
3. Relieved by rest or NTG
Possible cardiac:
- 2 of the above
- More common in DM and elderly
Non cardiac:
- 1 or none of the above
- non ischemic cardiac, pulmonary, GI, chest wall, psychiatric
Classification of angina
Class 1,2,3,4.
1: ordinary physical activity does not cause angina, such as walking and climbing stairs. Occurs with strenuous, rapid or prolonged exertion at work or recreation
- Slight imitation of ordinary activity, ex walking or climbing stairs
- Marked limitation of ordinary physical activity, walking 1-2 blocks
- Inability to carry on any physical activity without discomfort
Rest angina
New onset angina
Increasing angina
-Occurs at rest and usually prolonged >20mins
-At least CCS III within 2 mos of presentation
- Previously diagnosed angina worsening over < 4 weeks: more frequent, longer in duration, lower threshold
Learns the signs of heart attack
Chest discomfort
Sweating
Upper body discomfort
Nausea
Shortness of breath
Light headedness
Differentiating between Chest pain
Cardiac
GI
MSK
Cardiac: risk factors for CVD, heavy pressure, crushing, exertion of stress, rest or nitroglycerin
GI: Gastritis, burning, food, antacids
MSK: trauma, sore, achy, sharp, physical movement, rest, heat, or pain
