Week 2 Flashcards
What are the three most common causes of chest pain? Least common?
MSK Conditions, nonspecific chest pain, GI disease, Stable CAD
**Least Common: Unstable CAD
What is the prevalence of acute coronary syndrome in a walk in primary care office?
- 5%
1. 5 patients out of 100 of chest pain patients in primary care medical office have unstable heart disease
What indicators should trigger a call for an ambulance for a patient with chest pain?
Chest pain + respiratory distress or abnormal vital signs including erratic pulse or low BP
What associated symptoms should you ask a patient with chest pain? (3)
Confusion
Restlessness
Combination of dyspnea, palpitations, sweating
MFTPs in what muscles are most likely to mimic the pain associate with cardiac angina?
Scalenes
Pec major/minor
Serratus anterior
What are the top 3 clues that would suggest that a patient’s chest pain is not cardiac in origin?
Pain that is pleuritic - tied to breath cycle. Deep breath in = sharp pain
Pain that is positional
Pain that is reproducible with palpation ** this might be the best of the 3
What special ancillary tests are options for the initial round of testing patients for cardiac angina?
Resting EKG
Stress tests (3 types)
Chest radiograph
Angiography
What is the gold standard test?
Angiography is gold standard
How does the CAC test fit into a cardiac assessment?
Coronary artery calcium (CAC) test checks the number of calcium in your arteries. They do a CAT scan and measure amt of calcium build up in your coronary artery. More calcium = more risk. It’s expensive and many insurance companies don’t pay for it.
NOT a blood test, its a special CT scan.
What are other (5) risks for coronary artery disease derived from the patient’s history and physical?
1 Male
2 Family history
3 Increased hsCRP (highly sensitive chronic inflammation marker)
4 HRT (hormone replacement therapy)
5 Increased CAC (coronary artery calcium)
What blood tests are ordered to assess risk factors for coronary artery disease?
Lipid profile: HDL, LDL, total cholesterol
Glucose or Hgb A1C
hsCRP (highly sensitive)
**NOT a blood test: CAC
What is the classic triad of findings that suggest typical angina?
Substernal chest discomfort with a characteristic quality and duration
Provoked by exertion or emotional stress
Relieved by rest or nitroglycerin
What is a cardiac red flag
Chest pain that completely stops a patient from activity
What are clues from the history that increase the probability of acute MI (in order from highest to lowest LR)
Nausea
Both arms with pain
Right arm pain
What are tests are done in the ED to Dx MI?
And which tests shows permanent damage?
EKG
Troponins
Cardiac enzymes
Damage shown on EKG is permanent because that’s testing the cardiac muscle cell death
How are troponins tested?
Blood draws: takes 2-3 hours to show up in the blood, they peak around 12 hours and in 24 hours they’re gone
Cardiac enzymes CPK-MB follows the same pattern but is not recommended anymore but good board Q
What serious risk can arrhythmias subject a patient to?
Stroke or peripheral embolism
What are some of the common symptoms associated with arrhythmias?
1 - Irregularly irregular pulse
2 - Commonly tachycardic 110-140 beat/min
Also: palpitations, dyspnea, fatigue, dizziness, angina, and decompensated heart failure.
In addition, atrial fibrillation can be associated with hemodynamic dysfunction, tachycardia-induced cardiomyopathy, and systemic thromboembolism.
What percentage of arrhythmias are asymptomatic
90%
How does angina present?
Substernal chest pain with characteristic quality and duration
Provoked by stress, relieved by rest or nitro
What follow up tests should be ordered for angina
12 lead resting EKG
Stress tests (EKG, stress echocardiogram, myocardial perfusion scintigraphy)
Chest radiograph
Gold standard: angiography
What are the 3 stress tests?
EKG
Stress echocardiogram
Myocardial perfusion scintigraphy
Describe stress echocardiogram
US after the stress test
Describe myocardial perfusion scintigraphy
injection tagged with radioactive material and then the material will perfuse through the heart muscle. If coronary arteries are clogged and you do the stress test, those parts of the heart would not absorb the dye and so you think there is no blood there, aka its blocked.
What are big clues that suggest pericarditis
1 - non-pleuritic friction rub (sound of crackling like rubbing hair on pinnae of ear) so have them hold their breath and see if the sound goes away, then it is from the lungs. If it doesn’t go away, then it is from the heart
2 - precordial pain that radiates to trapezius ridge
3 - aggravated by supine posture, relieved by bending forward ***know this. So chest pain is worse when their heart rests toward their back and is better leaning forward.
4 - characteristic ECG/EKG electrocardiogram
P aggravated by supine posture, relieved by bending forward. What might this be?
Pericarditis
When their heart rests toward their back, the pain is worse and better when they lean forward.
What is a big clue for valvular disease?
Mid systolic murmur or closing click
What is a mid systolic murmur?
Lub swish dub
What is a closing click
Click dub
What ancillary study should be ordered for a valvular disease?
Stress Echocardiogram
Big clues for pleuritis?
Pleuritic pain, respiratory friction rub, fever/malaise
What follow up studies would you do for pleuritis?
Chest radiograph CBC Blood chem ESR ANA
What is a general test for lupus?
ANA
What arrhythmias required urgent/emergent medical referral?
Lower chamber - ventricular tachycardia and ventricular fibrillation
