MHD - Lec # 8 - Clinical Approach to chest pain

Question 1

What are the 4 killer chest pains?

Answer 1

1. Acute coronary syndrome (unstable angina/MI)
2. Pulmonary Embolism
3. Aortic Dissection
4. Tension Pneumothorax

Question 2

What are the 3 syndromes of Acute Coronary syndrome?

Answer 2

Unstable Angina
NSTEMI
STEMI

Question 3

Widened mediastinum and pleural effusion are characteristic of ______ ______.

Answer 3

Aortic Dissection

• sudden, tearing chest pain that radiates to the back

Question 4

What are some physical symptoms of acute CAD

Answer 4

Pallor
Sweating
Anxiety
Tachycardia
Rise in blood pressure
S4 gallop
Mitral regurgitation murmur
Paradoxically split S2
Pulsus alternans
(Pulsus alternans indicates impending LV failure and cardiogenic shock.)

Question 5

What are some indications for a stress test

Answer 5

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

Question 6

An EKG is a specific or sensitive test?

Answer 6

SPECIFIC
(85%; sensitivity is 70%)

• SPIN
• if positive rules IN disease

Question 7

What is IHSS? (Idiopathic hypertrophic sub aortic stenosis)

Answer 7

A cardiomyopathy characterized by marked hypertrophy of the left ventricle with asymmetrical hypertrophy of the IV septum out of proportion to the LV free wall (ASH), often resulting in a dynamic obstruction of the LV outflow tract.

Question 8

Classify Debakey Type 1,2, and 3 aortic dissection

Which can be corrected with surgery? Which is managed by medicine?

Answer 8

(stanford type A = 1 & 2)
1 – tear in ascending aorta, dissection moves distally (both)

2- originates & confined to ascending aorta

1and 2 = REQUIRE IMMEDIATE SURGERY!!!

(stanford type B)

3 = tear below the left subclavian
extend distally
difficult operation & generally managed medically via BP
= thoracic aorta

Stanford Type A - all dissections involving the proximal aorta

Stanford Type B - all dissections involving the distal aorta

Question 9

What are the 3 predisposing factors leading to Aortic Dissection?

Answer 9

HYPERTENSION
HYPERTENSION
HYPERTENSION!!!

HTN!!!!!!!! (most common)
pregnancy
congenital

• bicuspid aortic valve,
• coarctation,
• Marfan, Ehlers-Danlos

Widened Mediastinum on chest xray

Question 10

Describe the pain & signs of Aortic dissection

Answer 10

Pain:
Cataclysmic onset!!!
Most severe at onset, “tearing”, “stabbing” (in contrast, angina is slow progressing pain)

Tendency to migrate

Anterior thorax (proximal); interscapular (distal)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signs:
Pulse deficit (proximal), aortic regurgitation (proximal)
Neurological deficits (proximal) – CVA, paraparesis, peripheral neuropathy, vasovagal

Question 11

Of the non-cardiac causes of chest pain, which has the highest percentage of mortality/morbidity?

Answer 11

Pulmonary embolism has the greatest morbidity and mortality of the listed non-cardiac causes of chest pain.

Question 12

What are some GI causes of chest pain

Answer 12

Gastrointestinal
Gastroesophageal reflux
Diffuse esophageal spasm
Cholecystitis and cholelithiasis

Question 13

What are some Pulmonary causes of chest pain

Answer 13

Pulmonary
Pulmonary hypertension
Pneumothoraz
Pulmonary embolism

Question 14

What are some mental causes of chest pain

Answer 14

Emotional
Anxiety states
(hyperventilation)
Depression

Question 15

What are some Neuromuscular causes of chest pain

Answer 15

Neuromuscular
Herpes zoster
Cervical arthritis
Chest wall pain and tenderness

Question 16

What is a great test to rule out a PE?

Answer 16

D – Dimer - great test to rule out
negative= real negative predictive value
(sensitive)

if positive it does NOT help us
- need CXR usually

Question 17

What are some physical signs of calf vein thrombosis

Answer 17

• ASSYMMETRIC SWELLING associated with PAIN in the area of the calf below the obstruction