Symptom To Diagnosis - Chest Pain Flashcards
Anatomically organized DDx for chest pain - Main categories:
- Skin.
- Breast.
- Musculoskeletal.
- Esophageal.
- GI.
- Pulmonary.
- Cardiac.
- Vascular.
- Mediastinal structures.
- Psychiatric.
Chest pain - Skin pathology?
Herpes zoster.
Chest pain - Breast?
- Fibroadenomas.
2. Gynecomastia.
Chest pain - Musculoskeletal?
- Costochondritis.
- Precordial catch syndrome.
- Pectoral muscle strain.
- Rib fracture.
- Cervical or thoracic spondylosis (C4-T6).
- Myositis.
Chest pain - Esophageal?
- Spasm.
- Esophagitis - Reflux, medication-related.
- Neoplasm.
Chest pain - GI:
- Peptic ulcer disease.
- Gallbladder disease.
- Liver abscess.
- Subdiaphragmatic abscess.
- Pancreatitis.
Chest pain - Pulmonary - Pleura:
- Pleural effusion.
- Pneumonia.
- Neoplasm.
- Viral infection.
- Pneumothorax.
Chest pain - Pulmonary - Lung?
- Neoplasm.
2. Pneumonia.
Chest pain - Pulmonary - Pulm. Vasculature:
- PE.
2. Pulm. HTN.
Chest pain - Cardiac:
- Pericarditis.
- Myocarditis.
- Myocardial ischemia (angina, MI, unstable angina).
Chest pain - Vascular:
Thoracic aortic aneurysm or aortic dissection.
Chest pain - Mediastinal structures:
- Lymphoma.
2. Thymoma.
Stable angina can occur in the setting of normal or nearly normal coronary arteries and?
- Anemia.
- Tachycardia of any cause (A-fib, hyperthyroidism).
- Aortic stenosis.
- HCM.
- HF - Result of high filling pressures.
Stable angina - Eliciting factors other than exercise:
- Cold weather.
- Extreme moods (anger, stress).
- Large meals.
Stable angina - Symptoms other than chest pain:
- Dyspnea.
- Nausea or indigestion.
- Pain in areas other than the chest (eg, jaw, neck, teeth, back, abdomen).
- Palpitations.
- Syncope.
- Weakness and fatigue.
Traditional risk factors for stable angina:
- Male sex.
- Age >55 in men/ >65 in women.
- Tobacco use.
- Diabetes.
- HTN.
- Family history (before 55).
- Abnormal lipids.
Other risk factors for CAD:
- Hyperhomocysteinemia.
- Elevated levels of inflammation (CRP).
- Plasma fibrinogen.
- Microalbuminuria
- Cocaine - not a factor, but can cause angina and MI.
Women describe their CAD chest pain differently…?
Using terms like “burning” and “tender” more frequently.
3 major questions during history of chest pain:
- Is your chest discomfort substernal? (Where is your pain?).
- Are your symptoms precipitated by exertion?
- Does rest provide prompt relief of your symptoms (within 10 min)?
0/3 questions –> Asymptomatic.
1/3 questions –> Non angina, chest pain.
2/3 questions –> Atypical angina.
3/3 questions –> Typical angina.
Men over 50 and women over 60 who present with symptoms of typical angina have over a …% likelihood of having CAD.
90.
Factors that make the diagnosis of CAD less likely include:
- Unremitting pain of prolonged duration.
2. Other explanations for the patient’s symptoms.
Initial tests that should be done at the initial presentation of chest pain?
- Glucose and lipid profile because they can identify diseases that increase the likelihood of chest pain being ischemic in origin.
- Hb and TSH because they can identify other diseases that may cause angina.
- Resting ECG because it looks for evidence of previous infarction.
- Troponin - if symptom particularly severe or long-lasting.
Role of exercise testing in stable angina:
For 2 main purposes:
- To diagnose CAD.
- To determine whether patients should be treated with medications, PCI, or with bypass surgery.
The decision whether to order a routine exercise test or one with imaging is difficult. Definite reasons to obtain imaging are:
- Abnormal resting ECG.
- Previous coronary artery bypass grafting surgery (CABG) or PCI.
- A more sensitive test is required to rule out CAD, such as in patients with high likelihood of CAD.
Gold standard for diagnosing CAD:
Angiography.
Indications for patients with stable angina to undergo angiography:
- Abnormal stress indicating substantial ischemia.
- Ischemia at a low workload on an exercise test.
- Diagnostic uncertainty after an exercise test.
Patients may undergo angiography without first having an exercise test in the 2 circumstances when they will almost certainly require invasive therapy (PCI or CABG):
- Symptoms are disabling despite therapy.
2. When they have HF.
Exercise ECG - depression >1mm:
Sens - 65-70%.
Spec - 70-75%.
LR+= 2.5.
LR-= 0.45.
Exercise echo:
Sens - 80-85%.
Spec - 80-85%.
LR+= 4.8.
LR-= 0.21.
Dobutamine Echo:
Sens - 80-85%.
Spec - 85-90%.
LR+= 6.7.
LR-= 0.23.
Exercise myocardial perfusion SPECT:
Sens - 85-90%.
Spec - 85-90%.
LR+= 6.9.
LR-= 0.15.
Pharmacologic myocardial SPECT:
Sens - 80-90%.
Spec - 80-90%.
LR+= 7.
LR-= 0.18.
Patients with stable angina have about …%/yr risk of both MI and death.
3%.
Pill esophagitis is associated with:
- Biphosphonates.
- Tetracyclines.
- Anti-inflammatories.
- KCl.
Chest pain more likely to be of esophageal than cardiac origin?
Will be:
- Persistent.
- Wakes patient from sleep.
- Positional.
- Associated with a heartburn or regurgitation.
It is interesting that only …% of patients with an esophageal cause of pain in one study had GI symptoms (heartburn, regurgitation, dysphagia, vomiting).
83%.
Striking were some of the features NOT significantly different between the 2 groups (cardiac and esophageal cause of chest pain):
- Radiation to left arm.
- Exacerbation with exercise.
- Relief with nitroglycerin.
Is response to nitroglycerin useful in differentiating esophageal from cardiac cause of chest pain:
NO.
Gold standard for diagnosing GERD:
Esophageal pH testing - seldom necessary.
The combination of a suspicious history and consistent endoscopic findings has a …% specificity for GERD:
97%.
Indications for esophago-gastro-duodenoscopy (EGD):
- Symptoms of complicated disease (Dysphagia, extra-esophageal symptoms, bleeding, weight loss, chest pain of unclear etiology).
- Risk for Barrett.
- Require long term therapy.
- Respond poorly to appropriate therapy.
Indications for ambulatory pH monitoring:
- In patients with symptoms of GERD and a normal endoscopy.
2. To monitor therapy in refractory cases.
GERD - Surgery has higher or lower mortality than those treated medically at a mean follow-up of about 11 years:
Higher mortality.
The universal definition of MI describes 5 subtypes of MI based on their clinical presentation:
- Spontaneous MI related to ischemia due to primary coronary event.
- MI secondary to ischemia due to either increased O2 demand or decreased supply, eg, coronary artery spasm, anemia, or arrhythmias.
- Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischemia.
- MI associated with PCI or stent thrombosis.
- MI associated with CABG.
About …% of patients who are admitted to the emergency department with chest pain are having an MI.
15%.
Patients with chest pain should have an ECG within … of arriving at a healthcare facility.
10min.
Prevalence rates of MI among emergency department patients with chest pain and various ECG findings follow:
- New ST elevation of 1mm: 80%.
- New ST depression or T wave inversion: 20%.
- No new changes in a patient with a known CAD: 4%.
- No new changes in a patient without known CAD: 2%.
AMI - LR+ of historical features and physical exam findings:1
- Radiation to left arm - 2.3.
- Radiation to right shoulder - 2.9.
- Radiation to both arms - 7.1.
- Nausea and vomiting - 1.9.
- Diaphoresis - 2.0.
- S3 - 3.2.
- Hypotension - 3.1.
- Crackles - 2.1.