MHD: Chest Pain

Question 1

What are the most common causes of non-emergent chest pain?

Answer 1

Musculoskeletal (36%)
GI (19%)
Cardiac (16%)
Psych (8%)
Pulmonary (5%)

Question 2

What are the emergent causes of chest pain?

Answer 2

Acute coronary syndromes
Pulmonary embolism
Aortic dissection
Tension pneumothorax

Question 3

List the common cardiac causes of chest pain

Answer 3

Angina
MI
Aortic valve disease
Hypertrophic or congestive cardiomyopathy
Aortic dissection
Pericarditis
Mitral valve prolapse

Question 4

Describe the 3 locations of pain associated with chest pain

Answer 4

Most common: substernal

2nd: Epigastric and along the medial left arm
3rd: Neck, right shoulder, medial right arm

Question 5

How is cardiac chest pain classically described?

Answer 5

Crushing pain, pressure, tightness

Over 50% of the time this indicates cardiac involvement (30% angina, 24% MI)

Question 6

What are the physical signs of acute CAD?

Answer 6

Pallor, sweatting, anxiety, tachycardia, elevated BP, S4 gallop, mitral regurgitation murmur, paradoxically split S2, pulsus alterans

Question 7

What are the 3 categories of acute coronary syndrome?

Answer 7

Unstable angina
NSTEMI
STEMI

Question 8

Describe how daily activities can trigger coronary thrombosis

Answer 8

A vulnerable atherosclerotic plaque can rupture due to stress.
Minor ruptures can lead to nonocclusive thrombi and unstable angina, or a nonQ MI
Major ruptures can lead to occlusive thrombus and MI or sudden cardiac death

Question 9

What is the #1 diagnostic tool for acute MI?

Answer 9

ECG

50% will show typical signs of MI, 40% will be abnormal, but not diagnostic, and 10% will appear normal

Question 10

What are the ECG features of an acute infarction?

Answer 10

Elevated ST segments, inverted T waves and the development of Q waves

Question 11

What conditions often appear like an MI on ECG?

Answer 11

ECG impostors: Pericarditis, J-point elevation, WPW syndrome

Question 12

How does a posterior MI appear on ECG?

Answer 12

Reciprocal changes in the anterior leads (depressed ST segment, tall upright T waves, prominent R waves)

Question 13

What is a troponin lab test used for?

Answer 13

Lab test that is specific for cardiac injury ~24 hrs after MI

Question 14

What is stable angina?

Answer 14

Chest pain occurring with exertion in a predictable and consistent way

Question 15

Describe the sequence of ischemic changes that occur following an occlusion

Answer 15

Relaxation failure
Contraction failure
Increased filling pressure
ECG changes
Angina (~25 seconds after occlusion)

Question 16

Describe the Canadian cardiovascular society classification system for angina pectoris

Answer 16

I-IV scale with I and II representing stable angina, III and IV representing unstable angina.
Categories are separated based on the impact of physical activity

Question 17

What are the indications for a treadmill stress test?

Answer 17

Evaluation of chest pain
Estimating progress and severity of disease
Evaluation of therapy
Screening for latent coronary disease
Evaluation of arrhythmias

Question 18

Describe the ECG during an exercise stress test of a normal individual

Answer 18

Upsloping ST segment

Question 19

Describe the abnormal pathological finding on an ECG during an exercise stress test

Answer 19

Horizontal or downsloping ST segment

Question 20

How does pericarditis appear on an ECG?

Answer 20

Diffuse ST elevation

PR depression

Question 21

Describe the hemodynamics of aortic stenosis

Answer 21

The hardened aortic valve creates an increased pressure in the left ventricle during systole. This presents as a systolic ejection murmur.

Question 22

What is IHSS?

Answer 22

Idiopathic hypertrophic subaortic stenosis
Cardiomyopathy with asymmetrical hypertrophy of the intraventricular septum without equivalent hypertrophy of the free wall

Question 23

What are the GI causes of chest pain?

Answer 23

GERD
Esophageal spasm
Cholecystitis

Question 24

What are the pulmonary causes of chest pain?

Answer 24

Pulmonary hypertension
Pneumothorax
Pulmonary embolism

Question 25

What are the emotional causes of chest pain?

Answer 25

Anxiety

Depression

Question 26

What are the neuromuscular causes of chest pain?

Answer 26

Herpes zoster
Cervical arthritis
Chest wall pain/tenderness

Question 27

What is a pneumothorax?

Answer 27

Air in the pleural space

Question 28

How does tension pneumothroax become fatal?

Answer 28

Increased thoracic pressures can prevent blood flow to the heart, decreasing the hearts ability to pump blood and causing shock, rapid death

Question 29

What is the gold standard for diagnosing CAD?

Answer 29

Angiography