Track 1: Chest Pain, Acute Presentations and Risk Stratification

Question 1

Name some cardiac causes of chest pain (3)

Answer 1

• MI
• Angina
• Pericarditis/myocarditis

Question 2

Name some vascular causes of chest pain (3)

Answer 2

• Aortic dissection
• Pulmonary embolism
• Pulmonary arterial hypertension

Question 3

Name some pulmonary causes of chest pain (4)

Answer 3

• Pleuritis
• Pneumonia
• Tracheo-bronchitis
• Spontaneous PTX

Question 4

Name some causes of GI/MSK causes of chest pain (7)

Answer 4

• GERD
• PUD
• Cholecystitis
• Costochondritis
• Pancreatitis
• Cervical disc disease
• Herpes zoster

Question 5

If suspecting dx of unstable angina or acute MI, what needs to be started right away?

Answer 5

anticoagulation

Question 6

Name some key features of pericarditis

Answer 6

• Sharp, pleuritic
• Varies with body changes, relieved by sitting/leaning forward, worse with lying back
• Friction rub
• Splinted breathing
• Prodrome of viral illness
• Recent MI or CV procedure (especially ablation)

Question 7

Name some associated sxs which increase likelihood of MI
(Highest to lowest odds ratio)

Answer 7

• Radiation to right arm or shoulder
• Radiation to both arms or shoulders
• Associated with exertion
• Radiation to left arm
• Diaphoresis
• Nausea and vomiting
• Worse than previous angina or similar to prior MI
• Described as pressure

Question 8

Sx characteristics with a lower likelihood of ACS

Answer 8

• Pleuritic (sharp or knife like)
• Primary location in middle or lower abdomen
• Localized by 1 finger
• Reproduced with movement of the arms or head
• Reproduced with palpation of chest wall
• Pain present for many hours
• Very brief pain, only seconds
• Pain that radiates to the lower extremities

Question 9

Name some common anginal equivalents

Answer 9

• Jaw pain or ear pain
• Pain at side of neck
• Fullness in the base of neck
• Scapular or shoulder pain
• Nausea and vomiting

Question 10

Substernal chest pressure aggravated by exertion
Pain associated with dyspnea and right heart failure

Answer 10

Pulmonary hypertension

Question 11

Grace tool (older tool)

Answer 11

• Age
• HR
• SBP
• Cr
• Killip classification (HF)
• Cardiac arrest
• ST segment deviation (does not include T wave inversions)
• Abnormal cardiac enzymes
  *Big limitation: nothing about clinical picture

Question 12

HEART score (more recent tool)

Answer 12

• History, suspicion
• ECG
• Age
• Risk factors
• Initial Tn

Question 13

99th % for Tn at Mayo

Answer 13

15 male
10 female
* Must trend if chest pain onset < 6 hours

Question 14

Name the etiologies of MI (manifested by elevated Tn)

Answer 14

• MI (ACS)

Non ACS ischemia
- Type II MI (supply demand mismatch) (acute anemia, tachycardia, HCM)

Non-ischemic etiologies
- Structural heart disease
- Cardiotoxic agents

Question 15

Interpreting Hs-cTnT values

Answer 15

Question 16

Tip to interpreting HS-cTnT in the elderly population
What other special population?

Answer 16

Older patients tend to have higher baseline levels, pay close attention to delta for dx

Dialysis patients

Question 17

Hs-cTnT, elevation with delta at recheck > than what to diagnose acute MI

Answer 17

> 4

Question 18

Name some non ACS causes of high cTnT

Answer 18

Acute
- Demand supply mismatch (type II MI), tachy induced, hypertensive crisis, severe anemia
- Shock
- ICD shocks
- Sepsis
- Renal failure
- Severe pulmonary emboli

Chronic
- Severe aortic valve disease
- HCM
- Pulmonary hypertension
- Sarcoidosis
- Amyloidosis
- Hypertension

Acute or Chronic
- Coronary vasospasm
- Myopericarditis
- Chemotherapies
- Heart failure
- Cardiac pacing

Question 19

High sensitivity troponin T recommendations for appropriate use

Answer 19

Sex specific 99th percentile upper reference limit
- 15 ng/L men
- 10 ng/L women

2 hour rule out strategy
- Lack of delta, < 4 ng/dL

*Those with values > 100 ng/L and or changing pattern of values ≥ 10 ng/L are a population mcuh more likely to have acute MI

Question 20

Describe the one use of single sample rule out with hs-cTnT

Answer 20

Onset of sxs ≥ 6 hours from presentation, without symptom recurrence, in whom normal hx-cTnT concentration < 99th percentile
Rule out

Question 21

Though delta must also be taken into account what level of hs-cTnT should make you concerned about acute MI

Answer 21

> 100 ng/L (especially if patient has underlying kidney disease and is older), > 50 would also be a value to remember and a younger overall healthier patient

Question 22

Braunwald and 2021 chest pain guidelines still need completed