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CMN574 > Module 1 - Chest Pain/Heart Disease > Flashcards

Module 1 - Chest Pain/Heart Disease Flashcards

1
Q

Modifiable risk factors for chest pain

A

Lipid disorders
HTN
Cigarette smoking

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2
Q

Nonmodifiable risk factors associated with chest pain

A

Age (older)
Sex (male before menopause)
Family hx of early coronary disease

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3
Q

What can cause chest pain?

A

Cardiovascular disorders
Pulmonary disorders
Pleural disorders
Musculoskeletal disease
GI disorders (esophageal disorders)
Herpes zoster
Cocaine use
Anxiety states

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4
Q

Life threatening causes of chest pain

A

acute coronary syndrome (ACS)
Pericarditis
Aortic dissection
Vasospastic angina
pulmonary embolism
Esophageal perforation

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5
Q

Conditions (diseases) associated with increased risk of coronary artery disease

A

-SLE
-RA
-Reduced estimated GFR
-HIV infection
-Precocious ACS (acute coronary syndrome)

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6
Q

Chest Pain: PE
-What sx do patients present with?

A

SOB, chest pain, anxious

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7
Q

VTE risk factors

A

-Cancer
-Trauma
-Recent surgery
-prolonged immobilization
-Pregnancy
-oral contraceptives
-family hx and prior hx of VTE
-COVID

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8
Q

Chest Pain: PE
-other conditions associated with increased risk of PE

A

-HF
-COPD
-Sickle cell anemia
-Carbon monoxide poisoning
-Increased circulatory volume
-COVID

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9
Q

Chest Pain: PE
-clinical findings: Sx

A

-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

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10
Q

Chest Pain: MI
-how long does it take for pain to subside (stable angina)

A

5-20 minutes, but could last longer

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11
Q

Chest Pain: MI (stable angina)
-Is pain onset gradual or acute?

A

Gradual

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12
Q

Chest Pain: MI
-what is pain usually accompanied by?

A

anxiety and uneasiness

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13
Q

Chest Pain: MI
-what is usually normal when these patients present?

A

Physical assessment

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14
Q

Chest Pain: MI
-where is the pain located?

A

Retrosternal or left precordial

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15
Q

Chest Pain: MI
-where does pain tend to refer to?

A

-Throat, lower jaw, shoulders, inner arms, upper abd, back

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16
Q

Chest Pain: MI
-what can ischemic pain be cause/exacerbated by?

A

-exertion
-cold temp
-meals
-stress
-combination of these factors

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17
Q

Chest Pain: MI (stable angina)
-what is ischemic pain usually relieved by?

A

Rest (and nitroglycerine)

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18
Q

Atypical presentations of ACS are more common in:

A

Older adults
DM
Women

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19
Q

Chest Pain: other sx that are associated with ACS

A

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

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20
Q

What ACS symptom is strongly associated with an acute situation?

A

Vomiting

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21
Q

What ACS sx is a common presenting complaint in older persons?

A

Fatigue

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22
Q

Clinical features of acute MI:
-from hx (sx)

A

-chest pain that radiates to left, right, or both arms
-Diaphoresis
-N/V

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23
Q

Clinical features of acute MI:
-From physical examination

A

-Auscultate for third heart sound
-systolic BP <=80mmHg
-Pulonary crackles auscultated

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24
Q

Clinical features of acute MI:
-from ECG

A

-Any ST-segment elevation greater than or equal to 1mm
-Any ST depression
-Any Q wave
-Any conduction defect
-New conduction defect

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25
Q

What clinical findings and risk factors are most suggestive of ACS?

A

-prior abnormal stress test
-Peripheral arterial disease
-Pain radiating in both arms

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26
Q

ECG findings associated with ACS

A

-ST-segment depression
-any evidence of ischemia
-risk scores from hx, ECG, age, RF performed well in detecting ACS

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27
Q

Chest Pain: Pericarditis
-What position is pain worse?

A

greater when supine

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28
Q

Chest Pain: Pericarditis
-What makes pain increase?

A

-Increases with breathing, coughing, or swallowing

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29
Q

Chest Pain: Pleuritic chest pain
-ischemic or not ischemic?
-what does pain with palpation indicate?

A

-not ischemic
-musculoskeletal cause

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30
Q

Chest Pain: aortic dissection
-abrupt or gradual?
-sx
-where does pain radiate?

A

-abrupt
-tearing pain of greater intensity
-back

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31
Q

Chest Pain: PE
-how often is chest pain present with PE?
-what is the chief objective during evaluation of these patients?

A

-75% of cases
-assess pt’s clinical risk for VTE based on medical hx and associated sx and signs

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32
Q

Chest Pain: Rupture of thoracic esophagus
-What can cause this pain?

A

-Iatrogenically (induced unintentionally by a physician or surgeon, by medical treatment, or diagnostic procedures)
Secondary to vomiting

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33
Q

Should the physical examination be used as a sole basis for ruling in or out ACS diagnoses?

A

NO

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34
Q

Chest Pain: aortic dissection
-aortic dissection can result in?
-commonly has comorbidity of?

A
  1. differential BPs (greater than 20mmHg) 2. Pulse amplitude deficits 3. New diastolic murmur
    -HTN with systolic BP less than 100mmHg
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35
Q

Cardiac friction rub
-what does this represent?
-when can this best be heard?
-what needs to be excluded in all pts?

A

-Pericarditis
-sitting forward at end-expiration
-tamponade

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36
Q

Chest Pain: diagnostic studies

A

-ECG
-exercise stress test
-chest radiography
-stress ECG
-high-sensitivity troponin assay

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37
Q

Chest Pain: ECG findings with ACS

A

-ST-segment elevation is strongest predictor of acute MI
-Q wave

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38
Q

Chest Pain: exercise stress test
-who is this used with?
-what provider oversees this?

A

-clinically stable pts with CV disease risk factors, normal ECG, normal cardiac biomarkers, and no alternative dx (i.e. GERD or costochondritis)
-cardiologist

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39
Q

Chest Pain: Chest radiography
-is this even useful in evaluation of chest pain?
-when is this always indicated?
-what is consistent with esophageal perforation?

A

-YES! useful in eval of chest pain
-ALWAYS indicated when cough or SOB accompanies chest pain
-pneumomediastinum or new pleural effusion

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40
Q

Chest Pain: stress echocardiography
-who oversees this test modality?

A

cardiology

41
Q

Chest Pain: High-sensitivity troponin assay
-what does this determine?
-what is this the highest predictive value for?

A

-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

42
Q

Chest Pain: PE
-what is the diagnostic test that is helpful?

A

D-dimer

43
Q

Chest Pain: panic disorder
-how common is this disorder in causing pain (%)?
-features that correlate with inc likelihood of panic disorder?

A

-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

44
Q

Chest Pain: treatment
-what is treatment guided by?

A

-Guided by underlying etiology

45
Q

What are the most common sx of heart disease?

A

chest pain
dyspnea
palpitations
syncope or presyncope
fatigue

46
Q

What other things can cause chest pain?

A

pulmonary
pleural
musculoskeletal
esophageal or GI disorders
anxiety states

47
Q

What represents unstable angina? (what sx?)

A

progressive sx or sx at rest

48
Q

Is true angina related to position, respiration? Is it elicited by chest palpitations?

A

-NO
-NO

49
Q

what can mask sx of chest pain in women?

A

depression

50
Q

What is a HEART score? What does it determine?

A

-history, ECG, age, RF, troponin
-distinguishes coronary chest pain from noncoronary chest pain

51
Q

what two items improve sensitivity and specificity of diagnosing an acute coronary syndrome?

A

HEART score and troponin level

52
Q

Other causes of chest pain:

A

-hypertrophy of either ventricle
-myocarditis, pulmonary HTN, mitral valve prolapse
-Pericarditis
-Pleuritic chest pain
-aortic dissection

53
Q

NYHA Functional Classification of Heart Disease
-Class I

A

no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, or anginal pain

54
Q

NYHA Functional Classification of Heart Disease
-Class 2

A

slight limitation of physical activity. Ordinary physical activity results in sx

55
Q

NYHA Functional Classification of Heart Disease
-Class 3

A

marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes sx

56
Q

NYHA Functional Classification of Heart Disease
-Class 4

A

unable to engage in any physical activity without discomfort; sx may be present even at rest

57
Q

NYHA Functional Classification of Heart Disease
-Class 5

A

used by some experts to describe sx that are atypical and can occur either at rest or with exertion

58
Q

what is the preferred diuretic used to heart disease?

A

chlorthalidone

59
Q

what can the ECG show us related to heart failure?

A

valvular abnormalities
congenital abnormalities
chamber size/hypertrophy
presence of pericardial effusions

60
Q

on ECG, what is indicative of MI or ischemia?

A

ST changes or T wave changes

61
Q

what lab has a major role in defining cardiac risk factors?

A

CMP: serum lipid levels, serum human c-reactive protein level, serum creatinine

62
Q

what does serum BNP and NT-proBNP levels tell you?

A

helps determine if dx is congestive heart failure; can determine if congestive HF is being treated well enough
-quantitates the severity of heart failure

63
Q

What inflammatory marker is elevated with CAD?

A

CRP (hsCRP)

64
Q

*Causes of HF

A

-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

65
Q

*cardioselective BB

A

atenolol, bisoprolol, metoprolol, etc.
NOT propranolol, labetalol, carvedilol, pindolol

66
Q

What NYHA classification describes orthopnea and paroxysmal nocturnal dyspnea?

A

Class IV

67
Q

Murmurs: define stenosis

A

valve that is stuck shut

68
Q

Murmurs: define regurgitation

A

leaking valve; insufficient

69
Q

Murmurs: where is the aortic valve auscultated?

A

R 2nd intercostal space right of sternal border

70
Q

Murmurs: where is the pulmonic valve auscultated?

A

left 2nd intercostal space left of sternal border

71
Q

Murmurs: where is the tricuspid valve auscultated?

A

left 5th intercostal space left of sternal border

72
Q

Murmurs: where is the mitral valve auscultated?

A

apex (PMI) - left intercostal space midclavicular line

73
Q

*PMI, high pitched sound. What murmur is this?

A

Mitral, regurgitation

74
Q

What valves are open during systole?

A

Aortic and pulmonic

75
Q

What valves are open during diastole?

A

Tricuspid and mitral

76
Q

What heart sound does systole correlate with?

A

S1, lub

77
Q

What heart sound correlates with diastole?

A

S2, dub

78
Q

What sound does a stenotic valve make?

A

low pitched, harsh quality

79
Q

What sound does a regurgitant valve make?

A

high pitched flowing quality

80
Q

*What does a CHADVASC score of 3 indicate for tx?

A

Woman; anticoagulation therapy; oral anticoagulation is recommended
-DO NOT CHOSE ASPIRIN!!!!!!!!! It is minimally effective and not used for stroke prevention in Afib.

81
Q

CHADVASC scores
-when to offer anticoagulation therapy?

A

> =1 score with additional stroke risk factor
women is truthfully >=2 with additional risk factor

82
Q

*What is BNP used to dx?

A

Degree of HF

83
Q

*When is troponin found in labwork?

A

MI

84
Q

*What are the directions for sublingual nitroglycerin use?

A

Can take sublingually every 5 minutes at onset of pain, 3x

85
Q

*What betablocker is the first line antianginal?

A

atenolol (cardioselective beta blockers); bisoprolo, metoprolol

86
Q

*What is the first line therapy for HFrEF?

A

ACE-I (ARB) + Diuretic??
*BB
*MRA

87
Q

HFpEF
-percent ejection fraction

A

> 40%

88
Q

HFrEF
-percent ejection fraction

A

<40%

89
Q

*if resistant to diuretic, what should you do?

A

Add HCTZ, chlorthalidone, indapamide (thiazide diuretic) to current diuretic
-administer for short duration during acute phase, with loop diuretic for synergistic effect

90
Q

*What arrhythmia has QRS irregularly irregular?

A

AFIB

91
Q

*What lab level should you watch on ACE-I or ARB?

A

K

92
Q

*what are we concerned about with spironolactone?

A

concern for hyperkalemia

93
Q

*If patient is on ARNI, what knowledge do we need to know?

A

Must have been able to tolerate high dose ACE-I/ARB

94
Q

*What common SE of ACE-I makes people stop the med?

A

Cough

95
Q

*What is the goal INR for patient on Warfarin?

A

Between 2-3

96
Q

*What betablockers are contraindicated with asthma?

A

noncardioselective: carvedilol (coreg), metoprolol, propranolol

97
Q

*What else does an ACE-I protect?

A

The Kidneys! Protective for diabetes.

98
Q

*
What has the highest impact on CAD?
-elevated HDL
-elevated LDL
-low triglycerides

A

-elevated LDL

99
Q

ARNI is first line if:

A

-Stable mod-mild reduced EF
-BNP elevated
-hospitalized w/ HF in <=12MO
-systolic BP >100, GFR >30

CMN574 (6 decks)

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