Symptom To Diagnosis - Chest Pain Flashcards
1
Q
Anatomically organized DDx for chest pain - Main categories:
A
- Skin.
- Breast.
- Musculoskeletal.
- Esophageal.
- GI.
- Pulmonary.
- Cardiac.
- Vascular.
- Mediastinal structures.
- Psychiatric.
2
Q
Chest pain - Skin pathology?
A
Herpes zoster.
3
Q
Chest pain - Breast?
A
- Fibroadenomas.
2. Gynecomastia.
4
Q
Chest pain - Musculoskeletal?
A
- Costochondritis.
- Precordial catch syndrome.
- Pectoral muscle strain.
- Rib fracture.
- Cervical or thoracic spondylosis (C4-T6).
- Myositis.
5
Q
Chest pain - Esophageal?
A
- Spasm.
- Esophagitis - Reflux, medication-related.
- Neoplasm.
6
Q
Chest pain - GI:
A
- Peptic ulcer disease.
- Gallbladder disease.
- Liver abscess.
- Subdiaphragmatic abscess.
- Pancreatitis.
7
Q
Chest pain - Pulmonary - Pleura:
A
- Pleural effusion.
- Pneumonia.
- Neoplasm.
- Viral infection.
- Pneumothorax.
8
Q
Chest pain - Pulmonary - Lung?
A
- Neoplasm.
2. Pneumonia.
9
Q
Chest pain - Pulmonary - Pulm. Vasculature:
A
- PE.
2. Pulm. HTN.
10
Q
Chest pain - Cardiac:
A
- Pericarditis.
- Myocarditis.
- Myocardial ischemia (angina, MI, unstable angina).
11
Q
Chest pain - Vascular:
A
Thoracic aortic aneurysm or aortic dissection.
12
Q
Chest pain - Mediastinal structures:
A
- Lymphoma.
2. Thymoma.
13
Q
Stable angina can occur in the setting of normal or nearly normal coronary arteries and?
A
- Anemia.
- Tachycardia of any cause (A-fib, hyperthyroidism).
- Aortic stenosis.
- HCM.
- HF - Result of high filling pressures.
14
Q
Stable angina - Eliciting factors other than exercise:
A
- Cold weather.
- Extreme moods (anger, stress).
- Large meals.
15
Q
Stable angina - Symptoms other than chest pain:
A
- Dyspnea.
- Nausea or indigestion.
- Pain in areas other than the chest (eg, jaw, neck, teeth, back, abdomen).
- Palpitations.
- Syncope.
- Weakness and fatigue.
16
Q
Traditional risk factors for stable angina:
A
- Male sex.
- Age >55 in men/ >65 in women.
- Tobacco use.
- Diabetes.
- HTN.
- Family history (before 55).
- Abnormal lipids.
17
Q
Other risk factors for CAD:
A
- Hyperhomocysteinemia.
- Elevated levels of inflammation (CRP).
- Plasma fibrinogen.
- Microalbuminuria
- Cocaine - not a factor, but can cause angina and MI.
18
Q
Women describe their CAD chest pain differently…?
A
Using terms like “burning” and “tender” more frequently.
19
Q
3 major questions during history of chest pain:
A
- 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.
20
Q
Men over 50 and women over 60 who present with symptoms of typical angina have over a …% likelihood of having CAD.
A
90.
21
Q
Factors that make the diagnosis of CAD less likely include:
A
- Unremitting pain of prolonged duration.
2. Other explanations for the patient’s symptoms.
22
Q
Initial tests that should be done at the initial presentation of chest pain?
A
- 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.
23
Q
Role of exercise testing in stable angina:
A
For 2 main purposes:
- To diagnose CAD.
- To determine whether patients should be treated with medications, PCI, or with bypass surgery.
24
Q
The decision whether to order a routine exercise test or one with imaging is difficult. Definite reasons to obtain imaging are:
A
- 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.
25
Gold standard for diagnosing CAD:
Angiography.
26
Indications for patients with stable angina to undergo angiography:
1. Abnormal stress indicating substantial ischemia.
2. Ischemia at a low workload on an exercise test.
3. Diagnostic uncertainty after an exercise test.
27
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):
1. Symptoms are disabling despite therapy.
| 2. When they have HF.
28
Exercise ECG - depression >1mm:
Sens - 65-70%.
Spec - 70-75%.
LR+= 2.5.
LR-= 0.45.
29
Exercise echo:
Sens - 80-85%.
Spec - 80-85%.
LR+= 4.8.
LR-= 0.21.
30
Dobutamine Echo:
Sens - 80-85%.
Spec - 85-90%.
LR+= 6.7.
LR-= 0.23.
31
Exercise myocardial perfusion SPECT:
Sens - 85-90%.
Spec - 85-90%.
LR+= 6.9.
LR-= 0.15.
32
Pharmacologic myocardial SPECT:
Sens - 80-90%.
Spec - 80-90%.
LR+= 7.
LR-= 0.18.
33
Patients with stable angina have about ...%/yr risk of both MI and death.
3%.
34
Pill esophagitis is associated with:
1. Biphosphonates.
2. Tetracyclines.
3. Anti-inflammatories.
4. KCl.
35
Chest pain more likely to be of esophageal than cardiac origin?
Will be:
1. Persistent.
2. Wakes patient from sleep.
3. Positional.
4. Associated with a heartburn or regurgitation.
36
It is interesting that only ...% of patients with an esophageal cause of pain in one study had GI symptoms (heartburn, regurgitation, dysphagia, vomiting).
83%.
37
Striking were some of the features NOT significantly different between the 2 groups (cardiac and esophageal cause of chest pain):
1. Radiation to left arm.
2. Exacerbation with exercise.
3. Relief with nitroglycerin.
38
Is response to nitroglycerin useful in differentiating esophageal from cardiac cause of chest pain:
NO.
39
Gold standard for diagnosing GERD:
Esophageal pH testing - seldom necessary.
40
The combination of a suspicious history and consistent endoscopic findings has a ...% specificity for GERD:
97%.
41
Indications for esophago-gastro-duodenoscopy (EGD):
1. Symptoms of complicated disease (Dysphagia, extra-esophageal symptoms, bleeding, weight loss, chest pain of unclear etiology).
2. Risk for Barrett.
3. Require long term therapy.
4. Respond poorly to appropriate therapy.
42
Indications for ambulatory pH monitoring:
1. In patients with symptoms of GERD and a normal endoscopy.
| 2. To monitor therapy in refractory cases.
43
GERD - Surgery has higher or lower mortality than those treated medically at a mean follow-up of about 11 years:
Higher mortality.
44
The universal definition of MI describes 5 subtypes of MI based on their clinical presentation:
1. Spontaneous MI related to ischemia due to primary coronary event.
2. MI secondary to ischemia due to either increased O2 demand or decreased supply, eg, coronary artery spasm, anemia, or arrhythmias.
3. Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischemia.
4. MI associated with PCI or stent thrombosis.
5. MI associated with CABG.
45
About ...% of patients who are admitted to the emergency department with chest pain are having an MI.
15%.
46
Patients with chest pain should have an ECG within ... of arriving at a healthcare facility.
10min.
47
Prevalence rates of MI among emergency department patients with chest pain and various ECG findings follow:
1. New ST elevation of 1mm: 80%.
2. New ST depression or T wave inversion: 20%.
3. No new changes in a patient with a known CAD: 4%.
4. No new changes in a patient without known CAD: 2%.
48
AMI - LR+ of historical features and physical exam findings:1
1. Radiation to left arm - 2.3.
2. Radiation to right shoulder - 2.9.
3. Radiation to both arms - 7.1.
4. Nausea and vomiting - 1.9.
5. Diaphoresis - 2.0.
6. S3 - 3.2.
7. Hypotension - 3.1.
8. Crackles - 2.1.
49
Patient with chest pain and >1mm ST elevations in 2 contiguous leads OR a new LBBB is having...?
Acute AMI and should receive immediate therapy.
50
Test LR+ for ECG findings in patients with chest pain for the diagnosis of AMI:
1. New ST elevation >1mm - 5.7-53.
2. New Q wave - 5.3-24.8.
3. Any ST elevation - 11.2.
4. New Q or ST elevation - 11.
5. New conduction defect - 6.3.
6. Any Q wave - 3.9.
7. T wave peaking - 3.1.
8. Any conduction defect - 2.7.
9. Any ECG abnormality - 1.3.
51
Troponin levels in patients with renal insufficiency:
1. Often elevated - Risk for false positive.
2. Patients with elevated TROPONIN levels at BASELINE will still have a diagnostic rise and fall with MI.
3. Higher baseline Troponin levels are predictive or poor cardiovascular outcomes.
52
AMI in women - Presentation:
Prodromal symptoms such as:
1. Fatigue.
2. Dyspnea.
3. Insomnia.
- Dyspnea, weakness, fatigue are also other common presenting symptoms.
53
Chest pain is present in ... of women at the time of the MI:
57%.
54
About ... of patients with AMI are discharged from the emergency department.
2%.
55
A patient with an MI or unstable angina who is mistakenly discharged is most likely to:
1. Be a woman younger than 55.
2. Be non white.
3. Have a chief complaint of shortness of breath.
4. Have a non diagnostic ECG.
56
MI without chest pain:
Patients tend to be older women, or have DM, or have a history of HF.
57
Serial CK-MB <24h - Features:
Sens --> 99%.
Spec --> 98%.
LR+ 50.
LR- 0.01.
58
Serial CK-MB >24h - Features:
Sens - 55%.
Spec - 97%.
LR+ 18.
LR- 0.46.
59
Troponin I at 9h - Features:
Sens - 95%.
Spec - 98%.
LR+ 47.
LR- 0.03.
60
Troponin I >24h - Features:
Sens - 95%.
Spec - 98%.
LR+ 47.
LR- 0.03.
61
What is the main difference between AMI and unstable angina?
Enzymes.
62
...% of episodes occur in arteries with
67% in arteries with <50% stenosis.
63
...% occur in arteries with >...% stenosis:
97% in arteries with <75%.
64
The clinician seeing a patient with unstable angina or a NSTEMI must?
1. Recognize that the patient has an ACS.
2. Institute care.
3. Determine the patient's risk of progressing to an MI or death.
4. Treat accordingly.
65
Vasospastic angina - also called Prinzmetal or variant angina - has
Episodes of cardiac ischemia with ST elevation.
66
Vasospastic angina - The attacks:
1. Are often associated with chest pain or other ischemic symptoms.
2. Resolve spontaneously or with nitroglycerin.
3. May occur in normal or diseased coronary arteries.
4. Can result in MI or death (often 2o to arrhythmia).
5. Often occur at the same time each day (!).
67
Diagnosis of prinzmetal:
Usually clinically but can also be diagnosed by inducing it with ergonovine infusion in the catheterization laboratory.
68
Prinzmetal treatment:
Effectively with CCBs and nitrates.
69
Bottom line about vasospastic angina:
Should be considered in patients whose symptoms are consistent with cardiac ischemia and occur at about the same time each day.
Diagnosis should also be considered when transient ST elevations develop.
70
2-fold diagnostic considerations for a patient in whom angina is suspected:
1. Diagnose unstable angina.
| 2. NSTEMI and risk stratify the patient.
71
There are 3 presentations of unstable angina:
1. Rest angina.
2. New onset (<2months) angina.
3. Increasing angina.
72
Most commonly used score for evaluation of risk stratification in unstable angina/NSTEMI:
TIMI score.
73
TIMI score - Patients receive one point for each of the following variables:
1. Age >65.
2. Cardiac risk factors.
3. Prior coronary stenosis of >50%.
4. ST segment deviation on admission ECG.
5. >2anginal events in the preceding 24h.
6. Use of aspirin in previous 7 days.
7. Elevated cardiac biomarkers.
74
Other characteristics that portend high risk are:
1. Recurrent angina or ischemia at rest.
2. Elevated cardiac biomarkers at rest or with low-level activities despite intensive medical therapy.
3. Signs and symptoms of heart failure or new worsening mitral regurgitation.
4. High-risk findings from non invasive testing.
5. Hemodynamic instability.
6. Sustained ventricular tachycardia.
7. PCI within 6 months.
8. Prior CABG.
9. Reduced left ventricular function.
75
Physical exam in aortic dissection:
Asymmetry in the upper extremity BPs.
| Chest radiograph shows a widened mediastinum.
76
Primary risk factors for aortic dissection:
72% have HTN.
| 31% have atherosclerosis.
77
Other risk factors for aortic dissection:
1. Known aortic aneurysms - 16%.
2. Prior aortic dissection - 6%.
3. Diabetes - 5%.
4. Marfan syndrome - 5%.
78
Drug that may cause aortic dissection in younger patients:
Cocaine.
79
Type A aortic dissection mortality:
35%.
80
Type A aortic dissections may be associated with:
1. Acute aortic insufficiency.
2. Myocardial ischemia due to coronary occlusion.
3. Neurologic deficits.
4. Cardiac tamponade due to hemopericardium.
81
Type B aortic dissections mortality:
15%.
82
Mean age for aortic dissection:
63.
83
Aortic dissection - Presenting signs and symptoms were notable for the infrequency of some classic findings:
1. 15% --> Pulse deficit.
2. 9% --> Syncope.
3. 5% --> CVA.
4. 7% --> HF.
Chest X-ray and ECG were found to be very INSENSITIVE tools.
84
The aorta is normal in about ... of patients with a dissection of the thoracic aorta.
40%.
85
Prevalence of various findings and symptoms in patients with thoracic aortic aneurysm dissection (type A):
```
90% --> Severe or worst ever pain.
85% --> Abrupt onset pain.
79% --> Chest pain.
63% --> Widened mediastinum.
62% --> Sharp pain.
51% --> Tearing pain.
47% --> Back pain.
43% --> Non specific ST segment or T wave changes.
```
86
Aortic dissection - Fingerprint finding:
```
Test characteristics for pulse and BP differentials in a patient in whom aortic dissection is suspected were:
Sens - 37%.
Spec - 99%.
LR+ 37.
LR- 0.64.
```
87
Summarizing the clinical diagnosis of aortic dissection:
1. Patients with dissections are likely to have a history of HTN and experience severe, acute pain.
2. Patients with chest pain are unlikely to have a dissection if they do not have any of the following:
a. Acute or tearing or ripping pain.
b. Aortic or mediastinal widening.
c. Asymmetric pulse or BPs.
88
The gold standard for diagnosing aortic dissection is:
Angiography, but most patients undergo only non invasive tests.
89
Most commonly used tests for aortic dissection are:
CT scans and transesophageal echocardiography. Sens and spec over 95%.
90
Angiography in aortic dissection is recommended when?
To help guide the therapy if there is evidence of organ ischemia.
91
Incidences of several causes of pleural effusion:
```
HF --> 500.000
Pneumonia --> 300.000.
Malignancy --> 200.000.
PE --> 150.000.
Viral disease --> 100.000.
CABG --> 60.000.
Cirrhosis with ascites --> 50.000.
```
92
Causes of transudate:
1. HF.
2. Cirrhosis with Ascites.
3. 1/4 of PE.
4. Nephrotic syndrome.
93
Exudative effusions:
1. Parapneumonic effusions.
2. Malignancy.
3. 3/4 of PE.
4. Viral infections.
5. Post CABG.
6. Subdiaphragmatic infections and inflammatory states.
7. Chylothorax, uremia, connective tissue diseases.
94
What is considered a parapneumonic effusion?
Any effusion associated with pneumonia, lung abscess, or bronchiectasis.
95
Empyema is a parapneumonic effusion that has become?
Infected.
96
Parapneumonic effusions accompany ... of all pneumonias while empyemas occur ... of the time, at most.
40%, 2%.
97
Most common cancers leading to an effusion:
1. Lung.
2. Breast.
3. Leukemia.
4. Lymphoma.
5. Adenocarcinoma of unknown primary.
98
Effusions are present in ...-... of patients with PE.
26-56%.
99
Pleural effusions develop in up to ... of patients immediately following CABG.
90%.
100
About ... of patients with ASCITES have pleural effusions:
6%.
101
Sensitivity and specificity of dullness to chest percussion for detecting pleural effusions?
```
Very good.
Sens - 96%.
Spec - 95%.
LR+ 18.6.
LR- 0.04.
```
102
Light's criteria - Any effusion is considered to be an exudate if ANY of the following 3 criteria are met:
1. Pleural fluid protein/serum protein >0.5.
2. Pleural fluid LDH/serum LDH >0.6.
3. Pleural fluid LDH >2/3 upper limit of normal for serum LDH.
103
The most specific test for an EXUDATIVE effusion is?
A difference between the serum albumin and pleural fluid albumin of <1.2g/dL (LR+ 10.88).
104
Effusion pH - Low pH is usually seen with?
1. Empyemas.
2. Malignant effusions.
3. Esophageal rupture.
105
Cell count in effusions:
1. Neutros over 50% --> Pneumonia, PE.
2. Lymphocytes --> TB and malignancy.
3. Eosinophilia is a non specific finding.
4. Low mesothelial cell count <5% is highly suggestive of TB.
106
What is a very useful marker for diagnosing tuberculous pleurisy?
```
IFN-gamma.
Sens - 89%.
Spec - 95%.
LR+ 23.45
LR- 0.11.
```
107
Effusions with glucose levels <60mg/dL are seen in:
1. Empyemas.
2. TB.
3. RA and SLE.
108
Indications for chest tube placement are:
1. Purulent fluid or positive Gram stain.
2. pH 1.000U/L.
4. Glucose Small effusions that are close to the above 3 cutoffs can sometimes be carefully monitored.
109
Acute pericarditis - Textbook presentation:
1. Young adults - 1 week of viral symptoms and chest pai that improves with leaning forward.
2. Physical exam reveals a 3-part friction rub.
3. ECG reveals ST elevations and PR depressions in all leads.
110
85-90% of acute pericarditis are considered?
Idiopathic due to an undiagnosed virus:
1. Coxsackie.
2. Adeno.
3. Echo.
111
Drugs that cause pericarditis:
1. Procainamide.
| 2. Hydralazine.
112
About ... of patients with uremia have pericardial symptoms.
50%.
113
Pain of pericarditis classically radiates to?
The trapezius ridge.
114
Pericardial friction rub is?
Triphasic --> 58% of cases.
Biphasic --> 24%.
Monophasic --> 18%.
115
Sensitivity of JVD to detect tamponade is ?
100%.
116
Sensitivity of tachycardia to detect tamponade is?
100%.
117
Pulsus paradoxus for detecting tamponade?
Sens - 98%.
Spec - 83%.
LR+ 5.9
LR- 0.03.
118
ECG role in acute pericarditis:
Most commonly shows widespread ST elevations and Pr depressions. Highly specific but Sens is 60%.
119
The differentiation of pericarditis from AMI can be difficult. Some key points:
1. ST elevation in pericarditis is usually diffuse while in MI it is usually localized.
2. ST elevations in MI are often associated with reciprocal changes.
3. PR depression is very uncommon in acute MI.
4. Q waves are not present with pericarditis.
120
Cardiac enzymes in pericarditis:
Are frequently positive and are therefore NOT helpful for distinguishing chest pain or pericarditis from that of cardiac ischemia.
121
Few diagnostic tests for pericarditis:
1. Chest radiograph.
2. Bun and cr.
3. PPD.
4. ANA.
5. Blood cultures.
122
Main pivotal points when considering a history of chest pain:
1. Acuity of onset of the pain.
| 2. Whether or not the pain is pleuritic - worsening with inspiration.
