Track 1: Chest Pain, Acute Presentations and Risk Stratification Flashcards
Name some cardiac causes of chest pain (3)
- MI
- Angina
- Pericarditis/myocarditis
Name some vascular causes of chest pain (3)
- Aortic dissection
- Pulmonary embolism
- Pulmonary arterial hypertension
Name some pulmonary causes of chest pain (4)
- Pleuritis
- Pneumonia
- Tracheo-bronchitis
- Spontaneous PTX
Name some causes of GI/MSK causes of chest pain (7)
- GERD
- PUD
- Cholecystitis
- Costochondritis
- Pancreatitis
- Cervical disc disease
- Herpes zoster
If suspecting dx of unstable angina or acute MI, what needs to be started right away?
anticoagulation
Name some key features of pericarditis
- 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)
Name some associated sxs which increase likelihood of MI
(Highest to lowest odds ratio)
- 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
Sx characteristics with a lower likelihood of ACS
- 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
Name some common anginal equivalents
- Jaw pain or ear pain
- Pain at side of neck
- Fullness in the base of neck
- Scapular or shoulder pain
- Nausea and vomiting
Substernal chest pressure aggravated by exertion
Pain associated with dyspnea and right heart failure
Pulmonary hypertension
Grace tool (older tool)
- 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
HEART score (more recent tool)
- History, suspicion
- ECG
- Age
- Risk factors
- Initial Tn
99th % for Tn at Mayo
15 male
10 female
* Must trend if chest pain onset < 6 hours
Name the etiologies of MI (manifested by elevated Tn)
- MI (ACS)
Non ACS ischemia
- Type II MI (supply demand mismatch) (acute anemia, tachycardia, HCM)
Non-ischemic etiologies
- Structural heart disease
- Cardiotoxic agents
Interpreting Hs-cTnT values
Tip to interpreting HS-cTnT in the elderly population
What other special population?
Older patients tend to have higher baseline levels, pay close attention to delta for dx
Dialysis patients
Hs-cTnT, elevation with delta at recheck > than what to diagnose acute MI
> 4
Name some non ACS causes of high cTnT
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
High sensitivity troponin T recommendations for appropriate use
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
Describe the one use of single sample rule out with hs-cTnT
Onset of sxs ≥ 6 hours from presentation, without symptom recurrence, in whom normal hx-cTnT concentration < 99th percentile
Rule out
Though delta must also be taken into account what level of hs-cTnT should make you concerned about acute MI
> 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
Braunwald and 2021 chest pain guidelines still need completed
