Module 1 - Chest Pain/Heart Disease Flashcards
Modifiable risk factors for chest pain
Lipid disorders
HTN
Cigarette smoking
Nonmodifiable risk factors associated with chest pain
Age (older)
Sex (male before menopause)
Family hx of early coronary disease
What can cause chest pain?
Cardiovascular disorders
Pulmonary disorders
Pleural disorders
Musculoskeletal disease
GI disorders (esophageal disorders)
Herpes zoster
Cocaine use
Anxiety states
Life threatening causes of chest pain
acute coronary syndrome (ACS)
Pericarditis
Aortic dissection
Vasospastic angina
pulmonary embolism
Esophageal perforation
Conditions (diseases) associated with increased risk of coronary artery disease
-SLE
-RA
-Reduced estimated GFR
-HIV infection
-Precocious ACS (acute coronary syndrome)
Chest Pain: PE
-What sx do patients present with?
SOB, chest pain, anxious
VTE risk factors
-Cancer
-Trauma
-Recent surgery
-prolonged immobilization
-Pregnancy
-oral contraceptives
-family hx and prior hx of VTE
-COVID
Chest Pain: PE
-other conditions associated with increased risk of PE
-HF
-COPD
-Sickle cell anemia
-Carbon monoxide poisoning
-Increased circulatory volume
-COVID
Chest Pain: PE
-clinical findings: Sx
-dull, aching sensation of “pressure,” “tightness,” “squeezing,” or “gas,” rather than as sharp or spasmodic
-pain does not reach maximum intensity in seconds
-Ischemic sx usually subside within 5-20 minutes but may last longer
-Progressive sx or sx at rest may represent unstable angina
Chest Pain: MI
-how long does it take for pain to subside (stable angina)
5-20 minutes, but could last longer
Chest Pain: MI (stable angina)
-Is pain onset gradual or acute?
Gradual
Chest Pain: MI
-what is pain usually accompanied by?
anxiety and uneasiness
Chest Pain: MI
-what is usually normal when these patients present?
Physical assessment
Chest Pain: MI
-where is the pain located?
Retrosternal or left precordial
Chest Pain: MI
-where does pain tend to refer to?
-Throat, lower jaw, shoulders, inner arms, upper abd, back
Chest Pain: MI
-what can ischemic pain be cause/exacerbated by?
-exertion
-cold temp
-meals
-stress
-combination of these factors
Chest Pain: MI (stable angina)
-what is ischemic pain usually relieved by?
Rest (and nitroglycerine)
Atypical presentations of ACS are more common in:
Older adults
DM
Women
Chest Pain: other sx that are associated with ACS
SOB
Dizziness
Feeling of impending doom
Vagal sx (nausea and diaphoresis)
Fatigue is a common presenting complaint in older persons
Vomiting strongly associated with acute
What ACS symptom is strongly associated with an acute situation?
Vomiting
What ACS sx is a common presenting complaint in older persons?
Fatigue
Clinical features of acute MI:
-from hx (sx)
-chest pain that radiates to left, right, or both arms
-Diaphoresis
-N/V
Clinical features of acute MI:
-From physical examination
-Auscultate for third heart sound
-systolic BP <=80mmHg
-Pulonary crackles auscultated
Clinical features of acute MI:
-from ECG
-Any ST-segment elevation greater than or equal to 1mm
-Any ST depression
-Any Q wave
-Any conduction defect
-New conduction defect
What clinical findings and risk factors are most suggestive of ACS?
-prior abnormal stress test
-Peripheral arterial disease
-Pain radiating in both arms
ECG findings associated with ACS
-ST-segment depression
-any evidence of ischemia
-risk scores from hx, ECG, age, RF performed well in detecting ACS
Chest Pain: Pericarditis
-What position is pain worse?
greater when supine
Chest Pain: Pericarditis
-What makes pain increase?
-Increases with breathing, coughing, or swallowing
Chest Pain: Pleuritic chest pain
-ischemic or not ischemic?
-what does pain with palpation indicate?
-not ischemic
-musculoskeletal cause
Chest Pain: aortic dissection
-abrupt or gradual?
-sx
-where does pain radiate?
-abrupt
-tearing pain of greater intensity
-back
Chest Pain: PE
-how often is chest pain present with PE?
-what is the chief objective during evaluation of these patients?
-75% of cases
-assess pt’s clinical risk for VTE based on medical hx and associated sx and signs
Chest Pain: Rupture of thoracic esophagus
-What can cause this pain?
-Iatrogenically (induced unintentionally by a physician or surgeon, by medical treatment, or diagnostic procedures)
Secondary to vomiting
Should the physical examination be used as a sole basis for ruling in or out ACS diagnoses?
NO
Chest Pain: aortic dissection
-aortic dissection can result in?
-commonly has comorbidity of?
- differential BPs (greater than 20mmHg) 2. Pulse amplitude deficits 3. New diastolic murmur
-HTN with systolic BP less than 100mmHg
Cardiac friction rub
-what does this represent?
-when can this best be heard?
-what needs to be excluded in all pts?
-Pericarditis
-sitting forward at end-expiration
-tamponade
Chest Pain: diagnostic studies
-ECG
-exercise stress test
-chest radiography
-stress ECG
-high-sensitivity troponin assay
Chest Pain: ECG findings with ACS
-ST-segment elevation is strongest predictor of acute MI
-Q wave
Chest Pain: exercise stress test
-who is this used with?
-what provider oversees this?
-clinically stable pts with CV disease risk factors, normal ECG, normal cardiac biomarkers, and no alternative dx (i.e. GERD or costochondritis)
-cardiologist
Chest Pain: Chest radiography
-is this even useful in evaluation of chest pain?
-when is this always indicated?
-what is consistent with esophageal perforation?
-YES! useful in eval of chest pain
-ALWAYS indicated when cough or SOB accompanies chest pain
-pneumomediastinum or new pleural effusion
Chest Pain: stress echocardiography
-who oversees this test modality?
cardiology
Chest Pain: High-sensitivity troponin assay
-what does this determine?
-what is this the highest predictive value for?
-rapidly determines whether patient with chest pain has low risk (can be discharged from ED)
-Chest pain, ischemia on ECG, hx of ischemic heart disease
Chest Pain: PE
-what is the diagnostic test that is helpful?
D-dimer
Chest Pain: panic disorder
-how common is this disorder in causing pain (%)?
-features that correlate with inc likelihood of panic disorder?
-25% of cases present to ED
-Absence of CAD, atypical quality of chest pain, female sex, younger age, high level of self-reported anxiety, depression associated with recurrent chest pain w/ or w/o CAD
Chest Pain: treatment
-what is treatment guided by?
-Guided by underlying etiology
What are the most common sx of heart disease?
chest pain
dyspnea
palpitations
syncope or presyncope
fatigue
What other things can cause chest pain?
pulmonary
pleural
musculoskeletal
esophageal or GI disorders
anxiety states
What represents unstable angina? (what sx?)
progressive sx or sx at rest
Is true angina related to position, respiration? Is it elicited by chest palpitations?
-NO
-NO
what can mask sx of chest pain in women?
depression
What is a HEART score? What does it determine?
-history, ECG, age, RF, troponin
-distinguishes coronary chest pain from noncoronary chest pain
what two items improve sensitivity and specificity of diagnosing an acute coronary syndrome?
HEART score and troponin level
Other causes of chest pain:
-hypertrophy of either ventricle
-myocarditis, pulmonary HTN, mitral valve prolapse
-Pericarditis
-Pleuritic chest pain
-aortic dissection
NYHA Functional Classification of Heart Disease
-Class I
no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, or anginal pain
NYHA Functional Classification of Heart Disease
-Class 2
slight limitation of physical activity. Ordinary physical activity results in sx
NYHA Functional Classification of Heart Disease
-Class 3
marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes sx
NYHA Functional Classification of Heart Disease
-Class 4
unable to engage in any physical activity without discomfort; sx may be present even at rest
NYHA Functional Classification of Heart Disease
-Class 5
used by some experts to describe sx that are atypical and can occur either at rest or with exertion
what is the preferred diuretic used to heart disease?
chlorthalidone
what can the ECG show us related to heart failure?
valvular abnormalities
congenital abnormalities
chamber size/hypertrophy
presence of pericardial effusions
on ECG, what is indicative of MI or ischemia?
ST changes or T wave changes
what lab has a major role in defining cardiac risk factors?
CMP: serum lipid levels, serum human c-reactive protein level, serum creatinine
what does serum BNP and NT-proBNP levels tell you?
helps determine if dx is congestive heart failure; can determine if congestive HF is being treated well enough
-quantitates the severity of heart failure
What inflammatory marker is elevated with CAD?
CRP (hsCRP)
*Causes of HF
-aging
-systemic HTN - leads to left ventricular hypertrophy
-CAD - ischemia, MI, death of cardiac muscle with loss of ventricular wall motion
-cardiomyopathy
-tachyarrhythmias
-valvular lesions, myocardial ischemia, uncontrolled HTN, arrhythmias, alc/drug induced myocardial depression, hypothyroidism, intracardiac shunt
*cardioselective BB
atenolol, bisoprolol, metoprolol, etc.
NOT propranolol, labetalol, carvedilol, pindolol
What NYHA classification describes orthopnea and paroxysmal nocturnal dyspnea?
Class IV
Murmurs: define stenosis
valve that is stuck shut
Murmurs: define regurgitation
leaking valve; insufficient
Murmurs: where is the aortic valve auscultated?
R 2nd intercostal space right of sternal border
Murmurs: where is the pulmonic valve auscultated?
left 2nd intercostal space left of sternal border
Murmurs: where is the tricuspid valve auscultated?
left 5th intercostal space left of sternal border
Murmurs: where is the mitral valve auscultated?
apex (PMI) - left intercostal space midclavicular line
*PMI, high pitched sound. What murmur is this?
Mitral, regurgitation
What valves are open during systole?
Aortic and pulmonic
What valves are open during diastole?
Tricuspid and mitral
What heart sound does systole correlate with?
S1, lub
What heart sound correlates with diastole?
S2, dub
What sound does a stenotic valve make?
low pitched, harsh quality
What sound does a regurgitant valve make?
high pitched flowing quality
*What does a CHADVASC score of 3 indicate for tx?
Woman; anticoagulation therapy; oral anticoagulation is recommended
-DO NOT CHOSE ASPIRIN!!!!!!!!! It is minimally effective and not used for stroke prevention in Afib.
CHADVASC scores
-when to offer anticoagulation therapy?
> =1 score with additional stroke risk factor
women is truthfully >=2 with additional risk factor
*What is BNP used to dx?
Degree of HF
*When is troponin found in labwork?
MI
*What are the directions for sublingual nitroglycerin use?
Can take sublingually every 5 minutes at onset of pain, 3x
*What betablocker is the first line antianginal?
atenolol (cardioselective beta blockers); bisoprolo, metoprolol
*What is the first line therapy for HFrEF?
ACE-I (ARB) + Diuretic??
*BB
*MRA
HFpEF
-percent ejection fraction
> 40%
HFrEF
-percent ejection fraction
<40%
*if resistant to diuretic, what should you do?
Add HCTZ, chlorthalidone, indapamide (thiazide diuretic) to current diuretic
-administer for short duration during acute phase, with loop diuretic for synergistic effect
*What arrhythmia has QRS irregularly irregular?
AFIB
*What lab level should you watch on ACE-I or ARB?
K
*what are we concerned about with spironolactone?
concern for hyperkalemia
*If patient is on ARNI, what knowledge do we need to know?
Must have been able to tolerate high dose ACE-I/ARB
*What common SE of ACE-I makes people stop the med?
Cough
*What is the goal INR for patient on Warfarin?
Between 2-3
*What betablockers are contraindicated with asthma?
noncardioselective: carvedilol (coreg), metoprolol, propranolol
*What else does an ACE-I protect?
The Kidneys! Protective for diabetes.
*
What has the highest impact on CAD?
-elevated HDL
-elevated LDL
-low triglycerides
-elevated LDL
ARNI is first line if:
-Stable mod-mild reduced EF
-BNP elevated
-hospitalized w/ HF in <=12MO
-systolic BP >100, GFR >30
