Week 5 Chest pain Flashcards
What are the most common causes of chest pain in adolescents? what sx’s are those?
- 35% of chest pain is costochondritis (musculoskeletal)
- Insidious onset
- Persists for long period of time
- Positional component
- Began after repetitive use of an upper extremity
- 19% GI souce
- 16% idiopathic
Most common cause of sudden death in athlete
- Hypertrophy cardiomyopathies (25% of sport related deaths)
- # 2 is commotion cordis (20%) sudden blunt impact to chest causes sudden death, in absence of cardiac damage
what questions are important to ask in history for chest pain?
- Any history of sudden death in an immediate family member?
- Unexplained or exertional syncope (not after but during sports?
most common cause of myocarditis is
viral myocarditis
- enterovirus, esp coxackie B virus
- adenovirus surfaced to top of list of 25% cases
- influenza and subtypes (H1N1)
- in adolescent: parvovirus B19
when does exposure to the virus do you develop symptoms of chest pain?
can begin < 2 weeks after exposure
Lab findings for myocarditis
- elevated troponin I levels
- completely normal coronary artery angiogram
- ECG - low QRS with ST changes
- cardiac MRI - delayed gadolinium sparing the sub endocardium
- to diagnose: endomyocardial biopsy
if have viral myocarditis, the patient play sports?
No, refer to cardiologist for further management
sudden death with continued strenuous aerobic exercise in myocarditis (exercise allows virus to replicate = worsens disease = ventricular ectopy)
cardiologist will follow lifelong
if treadmill stress test and ECG are normal (wks-months)
acute coronary syndrome (ACS) sx’s
GET MORE HISTORY! then send to cardiac care facility for management
- since chest pain affects every organ, want MORE history and not imaging
- Worsening in the frequency, intensity, duration, and timing (ie, nocturnal pain, rest pain) of prior anginal or anginal equivalent symptoms
- New-onset shortness of breath, nausea, sweating, extreme fatigue in a patient with a known history of CVD
- Onset of typical anginal symptoms in a patient without a history of cardiovascular disease
- New findings on physical exam of murmur (or worsening of a previously noted murmur), hypotension, diaphoresis, rales or pulmonary edema
want to rule out psychiatric concerns bc
Domestic violence is one such cause of chest pain similar to myocardial infarction (MI)
ECG changes for acute coronary syndrome
- ST elevation (STEMI >1mm) / depression
- pathologic Q waves
- T waves
after completing a thorough hx/ E for chest pain…
Evaluate need for emergent care: if think ACS, chew an aspirin & go to ED.
ED also if seriously ill, such as pneumothorax, pulmonary embolism, pneumonia, aortic dissection, etc.
acute pericarditis diagnosis
triad
- pleuritic chest pain (stab/burn pain when breathing)
- pericardial friction rub (heard leaning forward at end expiration)
- diffuse ST wave elevation
what clinical features increase likelihood of it being an MI in patients?
- acute chest pain radiates to both arms
- 3rd heart sound
- hypotension
pain that worsens with inhalation
pleuritic chest pain
diagnostics for heart failure
- Echo
- chest xray
- ECG (structural heart disease, conduction disease)
- if normal = NOT HF
- hematocrit - anemia
- thyroid function - exclude thyroid dz
- fasting lipid panel and fasting glucose (and A1c) - screen for hyperlipidemia, metabolic syndrome, DM
- UA, BMP
- brain natriuretic peptide (BNP) - if normal = HF unlikely
standard diagnostic for coronary artery disease
coronary angiography
for any obstructive lesion producing sx’s or those at risk of ACS
when is a coronary angiography indicated
new systolic heart failure and angina
pt w/o angina with no previous evaluation of coronary anatomy d/t high prevalence of CAD in older adults
can exclude coronary anomalies in younger pts
3 most important factors that determine Oxygen demand is determined are:
- Heart rate
- systemic BP (peripheral vascular resistance)
- Left ventricular wall tension (anything that increases heart workload)
stable angina symptoms
- chest pain/discomfort from exertion, stress, large meals, cold weather
-
relieved in 1-3 mins by rest or by 1 nitroglycerin
-
< 5 mins
- if >20 mins pain = ACS
-
< 5 mins
- NOT localized pain
- Levine sign - make fist over sternal area
- substernal tightness / pressure
- more predictable
differentials to run out for chest pain
- r/o non-emergent causes
- GI
- Pulmonary
- Valvular inflammatory
- Integ
- Psychological disturbances
- Issues at home
- Domestic violence
- r/o life-threatening events
- Aortic dissection
- MI
- PE
- Spontaneous pneumothorax
unstable anginal sx’s
- At rest or minimal exertion chest pain, nausea, light headed, SOB, epigastric pain, diaphoretic skin
- not localized, not stabbing
- Persistent pain
- not relieved with rest or nitroglycerin
- > 10 mins
atypical symptoms of angina and more common in who?
- dyspnea, indigestion, nausea, numbness in the upper extremities, jaw pain, pleuritic pain, and fatigue (rather than actual chest pressure)
- more common in diabetics, women, elderly
If chest pain all the way to the back/ripping/tearing
- consistent aortic dissection
Gold standard/first line to diagnose unstable angina:
on ECG - looking for downsloping or horizontal ST depression
* Stress test/exercise tolerance test within 72 hrs of angina if EKG inconclusive
* want to reproduce the stress in the heart /dyspnea on exertion under controlled situations WHEN THEY ARE NOT HAVING CHEST PAINS
* less effective in women bc women have non obstructive or single vessel disease
*
Contraindications to stress test
- DO NOT DO IF ACTIVE MI sx’s, EKG changes, Cardiac in nature
- active chest discomfort
- Mobility issues
- Amputees
- Schedule with hip replacement
- Dementia
only put asymptomatic patients
secondary prevention for coronary artery disease/vascular disease checklist:
- complete smoking cessation
- BP < 140/90, < 130/80 if HF or renal insuff
- eval before statin, fasting lipid panel, ALT/CK
- if < 75: high intensity Atrovastatin 80mg/rosuvastatin 40mg
- if > 75: moderate statin
- reduce sat fat < 7%
- triglycerides < 200
- 30 min exercise x7 days
- BMI 18.5-24.9
- hemoglobin A1c < 7%
- aspirin 81mg QD (clopidgrel or warfarin if contraindicated)
- BB
- metformin
- ACE inhibitor (if have CKD or diabetes)
- influenza vaccine
Duke treadmill scores
- stress test point system to predict 5-year mortality using Bruce protocol
- ST-segment deviation (depression or elevation), and the presence and severity of angina during the exercise
- score = exercise duration (minutes) - 5*(ST deviation/mm) - 4*(angina index)
- low risk
- score > 5 = 5 year survival of 97%
- intermediate risk
- score between 4 and -10 = 90%
- high risk
- score < -11 = 65%
labs to check for stable angina
- Lipid profile
- Hemoglobin A1C
- CBC
- Anemia (limited myocardial oxygen supply)
- Hemoglbin < 7, can have ST segment/depression
- Polycythemia
- Thrombocytopenia
- Elevated platelets
- Anything that increases viscosity of blood = impedes flow
- Serum creatinine
- B-type natriuretic peptide (BNP) (evidence of HF)
coronary artery disease management
-
BB for ALL pt’s with MI, ACS, or Left ventricular dysfunction history
-
or CCB
- no BB if COPD
- can use Ranolazine (Ranexa) instead if bradycardia & can’t do BB/CCB
-
or CCB
- ACE inhibitors for ALL pts with ejection fraction < 40, HTN, DM, or CKD
- nitrate PRN
- aspirin, clopidogrel or warfarin
- statin
- flu shot
- if meds fail: coronary angiography (PCA)
- f/u q 4-6 months 1st year, then q 4-12 months
On ECG,
leads II, III, aVF are what views of the heart?
inferior wall ischemia/infarc
On ECG,
leads I, aVL, V5, V6 shows
lateral wall ischemia infarc
On ECG,
leads V3, V4 shows
Anterior wall ischemia/infarc - left anterior descending artery (LAD) blockage
On ECG,
leads V1, V2 shows
septal wall ischemia/infarc of heart
evolution of MI on ECG
- minutes: ST elevation
- hours: R ave, Q wave
- 1-2 days: T wave inversion, Q wave deeper
- days: ST normalizes, T wave inverted
- weeks: ST & T normal, Q wave persists
a U wave is benign if…
- benign if < 5mm
- small deflection after T wave
- can be acute MI, cardiomyopathy, hyperthyroidism, e- imbalance
if have 2 continuous ST segment elevation..
get to PCI capable center within 90 minutes for reperfusion
if can’t, give fibrinolytic therapy within 30 minutes
acute STEMI management
- Reperfusion therapy or fibrinolytic therapy
- Dual antiplatelet therapy
- Anticoagulation
- Aspirin, clopidogrel
- Short term anticoag (heparin) for 2-8 days
Non ST-segment Elevation-ASC management
- Detailed hx, PE
- 12 lead ECG within 10 minutes of arrival
- troponin I or T now and 3-6 hrs after sx onset
- chew aspirin 162-325 mg asap
- Oxygen if needed
- daily BB
- sublingual NTG
- heparin
what medications worsen heart failure? (heart is unable to meet the metabolic demands of the body)
- NSAIDs/Naproxen
- CCB - depresses myocardial contractility
angina treatment
- smoking cessation
- BP < 130/80 (CCB/ACE)
- statins
- PA 30 min/day 5-7x/wk
- BMI 18.5-24.9
- diabetes: Hgb A1C < 7%
- metformin for all diabetics with CAD
- also semaglutide, empaglifozin decrease CVD deaths in DM
if unstable angina, #1 thing to do next?
EKG w/in 10 mins! Leads will tell location
what is Thrombolysis in myocardial infarction (TIMI) score?
- risk score for unstable angina/NSTEMI
- 1 pt for:
- > 65
- _>_3 CAD risk factors (fam hx, HTN, HLD, Dm, current smoker)
- ASA in last 7 days
- elev cardiac markers (CK-MB or troponin)
- ST deviation > .5 mm, prior CAD > 50%
- 1 pt for:
- if score 5 (high): go to PCI center hospital within 90 mins
- if score 3-4 (intermediate): give ASA/nitrate, f/u in 72 hrs
ACS/MI workup/labs
- EKG w/in 10 mins
- draw troponin (peaks at 3-4 hrs) 3x, at presentation, 3 hrs, at 6 hrs
- elevated for a week
- Chest xray (r/o pneumonia, pneumothorax)
- CBC (anemia)
- BMP, fasting glucose, lipids, thyroid, mg
- consider CRP, BNP
- echo for wall motion
ACS/MI Treatment
- aspirin 325 chewable table asap
- NTG tab (unless had phosphodiesterase inhibitor 48 hrs ago)
- statin w/in 24 hrs of event
- BB w/in 24 hrs unless CI
- consider heparin bolus
- ALS transfer to hospital
unstable angina vs NSTEMI
- unstable angina: persistent ST segment depression > 1 mm for > 48 hrs
- no Q waves, no R waves
STEMI workup
- EKG (shows persistent ST segment elevation with no LV hypertrophy or LBB with elevated cardiac markers in 2 continuous leads
- ST elevation > 2mm in males, > 1.5 mm females
- new onset BBB
- Labs (troponin!!!! cardiac specific, CK-MB, myoglobin [earliest marker for cell injury but not cardiac specific)
- ECHO
Acute coronary syndrome
consists of:
- unstable angina
- NSTEMI
- STEMI
STEMI treatment:
- aspirin 325mg chewable tablet
- go to PCI center w/in 90 mins
- start fibrinolytic therapy w/in 30 mins if transfer takes longer then 2 hrs
- reperfusion therapy w/in 12 hrs onset
- post PCI: dual anti-platelet therapy (P2Y12 receptor inhibitor/Plavix and aspirin x 30 months)
- BB w/in 24 hrs
- ACE, CCB
- nitrates
Post MI
- future risk of CV events
- f/u cardiac rehab
- assess med compliance, SE, sx’s, risk factors, comorbidities
non invasive tests/biomarkers for CAD testing
C- reactive protein, interleukin -6, monocyte macrophage colony stimulating factor
Cardiac testing: C-reactive protein can be used in who for what?
- ASYmptomatic men 50+/women 60+ with LDL < 160 if statin therapy is needed
- assesses CVD risk
Cardiac testing: ankle brachial index (ABI)
assess intermediate risk for subclinical CVD
cardiac testing: CACS
coronary artery calcium scoring
0: normal
10: low
400: high
r/t to plaque burden, high radiation exposure
cardiac testing: exercise tolerance test/stress test NOT in who?
DON’T DO IN ASYMPTOMATIC PPL WITH NO HX OF REVASCULARIZATION
cardiac testing: exercise tolerance test/stress test indication & results?
- detects CAD in pt’s with angina or dyspnea on exertion who are at intermediate risk of ACS
- first line testing
- predicts future cardiac events/functional capacity
- normal ECG response: isoelectric ST segment during exercise and recovery
- positive ETT if horizontal/downsloping ST segment depression of 1 mm
- non dx if can’t reach target HR [220 - age], unless there are ST changes before max HR reached
- OR exercise induced hypotension (SBP falls 20+ any point during exercise)
what causes lowered specificity of an exercise tolerance test?
- prior MI
- BBB
- conduction abnormality
- pacer
- pre excitation syndrome or inability to exercise
Exercise TT medication management before ETT
if ETT ordered d/t angina, ask cardiologist if should stop BB 1-2 days before test
if ETT is to see current pharm regimen is effective → continue BB
contraindications to exercise TT
ABSOLUTE: active endocarditis, HF, MI past 2 days, can’t exercise, persistent stable angina, uncontrolled arrhythmias, heart blocks, aortic stenosis
relative CI: Complete heart block, cardiomyopathies, recent stroke/TIA, severe HTN, tachyarrhythmias
indications to add nuclear/ultrasound imaging to exercise TT
- Left ventricle hypertrophy with ST segment and T wave abnormalities on resting ECG
- baseline ST/T wave abnormalities on resting ECG
- recent MI
- use of digoxin
- Wolff-parkinson white syndrome, BBB, vent pacemaker
cardiac testing: exercise echocardiography
abnormal left ventricular EF or wall motion abnormalities using dobutamine
pharmacologic stress test
- for those that can’t exercise/treadmill
- use coronary vasodilators (dipyridamole (Persantine) and adenosine and inotropic chronotropic (dobutamine) [reversed with aminophylline] to unmask variations in flow NOT ischemia
- assess effective coronary flow reserve
- ECG 20% show angina
Types of Heart failure
- HF with reduced EF < 40%
- systolic HF
- can’t contract/empty = decrease CO
- HF with preserved EF > 50
- diastolic HF
- impaired vent filling/relaxation
- HF with mid range LVEF 40-49%
- sx’s both systolic and diastolic HF
left side HF vs right sided HF symptoms
- dyspnea and fatigue
- sx’s SUBLE due to fluid overload in body
- Left sided HF: fatigue dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, s3 or s4 heart sound, displaced apical pulse, crackles if pulmonary edema
- R sided HF (advanced L sided HF): LE edema, fatigue, exercise interlace, JVD, nocturia, ascites, hepatomegaly, nausea, S3 heart sound
HF compensations
- higher renin and adolsterone - Na retention = increases CO (give ACE/ARB)
- adrenergic to boost contractility (give BB)
- ventricular remodeling = dilation and thinning, worsens HF
NY Heart Association Functional Classification (based on Sx severity): Class 1
no limitations - asx with activity and rest
NY Heart Association Functional Classification (based on Sx severity): Class 2
- slight limitation. comfortable at rest
- Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath)
- ex: sx’s occur after climbing 1 flight of stairs but pt does not need to stop
NY Heart Association Functional Classification (based on Sx severity): Class 3
- Marked limitation of physical activity.
- Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea
- ex: pt can’t climb 1 full flight without stopping/ need break
NY Heart Association Functional Classification (based on Sx severity): Class 4
- inability to carry on any physical activity without discomfort and sx at rest
- ex: pt can’t climb more than 1 step or sx start when grooming
NY Heart Association Functional Classification (based on Sx severity): Class 5
- inability to carry on any physical activity without discomfort and sx at rest
- ex: pt can’t climb more than 1 step or sx start when grooming
ACC/AHA heart failure stages: Stage A
- high risk of HF
- NO SX’s or STRUCTURAL changes
- ex: pt with HTN, obesity, DM
ACC/AHA heart failure stages: Stage B
- STRUCTURAL changes but no sx’s
- ex: hx of MI with some remodeling, asx valvular heart disease, preheart failure
ACC/AHA heart failure stages: Stage C
- structural changes AND symptoms
- hx of sx’s of HF or current
ACC/AHA heart failure stages: Stage D
- ADVANCED structural changes
- symptoms at REST (despite max medical therapy)
- refractory HF (recurrent fluid overload, hospitalizations)
Framingham criteria for diagnosing Heart Failure
Need 2 major OR 1 major + 2 minor:
- major:
- acute pulmonary edema
- cardiomegaly
- hepatojuglar reflux
- neck vein distention
- paroxysmal nocturnal dyspnea/orthopnea
- minor
- ankle edema
- dyspnea on exertion
- hepatomegaly
- nocturnal cough
- pleural effusion
- tachycardia > 120 HR
HF workup
- CBC
- serum electrolytes
- Ca, Mg,
- BUN/Cr
- glucose
- lipids
- TSH, UA
- BNP
- N terminal proBNP
when is Brain natriuretic peptide (BNP) secreted? useful for? increased/decreased in?
- secreted by ventricular myocardial cells in response to elevation in END DIASTOLIC pressure and volume
- higher sensitivity than specificity → can rule out HF
- increased with age, ACS, anemia, COPD, pulmonary HTN
- lower in obese pt’s
- if pt on ARNI [Sacubitril/valsartan (Entresto)], draw pro BNP instead
- BNP > 50 = dx early HF in high risk pts
ECHO
- most effective tool in HF assessment
- assess ventricle thickness, function, EF, valve dz, regurg/stenosis, size, wall motion
if pt has HF with reduced EF NEW ONSET
send to cardiology!
how likely is HF with normal BNP and normal echo?
unlikely!
always r/o what with new onset of heart failure?
ACS!
heart failure management
- NO CCB, NSAIDs
- Na restriction, weight loss, med compliance
- hospitalization with new onset HF w/ sx/s fluid overload, suspect infarction, pulmonary edema with low O2 sats, unstable pts
- assess for obstructive sleep apnea
HF med management
target RAAS system!
- diuretics (relieve congestion): HCTZ or Loop
- titrate up if > 5lb gained in 2 days
- treat OSA, anemia, electrolyte imbalances etc
Stage A HF management
statin, BP < 130/80, control arrhythmias (BB, amio), manage diabetes
Stage B HF management
- BNP screening
- treat BP w/ ACEI/BB (carvedilol, metoprolol, bisoprolol)
- vascular repair if needed
- consider ICD placement if LVEF < 35%
Stage C HF management
*classify pt as either reduced/systolic HF or preserved/diastolic HF
-
systolic/R: BB, ACE-i/Arb/ARNI, thiazide/loop, aldosterone antagonist
- monitor renal, Cr, KCl
- hydralazine w/ isosorbide
- ivabradine
- digoxin
- ICD (if EF< 35%)
- diastolic/P: lifestyle, diuretics, treat comorbidities (DM, HTN, CAD)
Stage D HF management
consider LVAD/transplant
palliative care
when to refer for heart failure?
- sx’s refractory to standard therapies
- new stable arrhythmias
- new coronary ishcemia on EKG
- ALL young pt’s w/ dilated cardiomyopathy or worsening sx’s
when to hospitalize HF?*
- new onset HF with signs of congestion/fluid overload
- suspect infarction or ischemia
- pulmonary edema (pink frothy sputum)
- O2 < 90%
- unstable pts
- ACS/MI
- new arrhythmia w/ hemodynamic instability
Peripheral artery disease (PAD) screening
- All over 65
- all over 50 with hx of smoking or diabetes
- all with suspected PAD sx’s + non healing wounds
PAD hallmark sign and presentation *
- discomfort with activity “tiredness”, “giving way”, “soreness” “pain”
- hallmark: intermittent claudication
- tightening, cramping pain from exercise and alleviated by rest
- calf most common, thigh, butt (iliac artery obstruction/Leriche syndrome)
- severe: pain @ rest/awaken at night (alleviated by gravity)
*PAD exam
- distal hairloss
- shiny skin
- absent femoral pulses/femoral bruit
- muscle atrophy
- advanced:
-
dependent rubor (pale with elevate for 30 secs, then when dependent, deep red ensues
- longer it takes for rubber to get = worse ischemia
- skin ulcers
-
dependent rubor (pale with elevate for 30 secs, then when dependent, deep red ensues
PAD initial diagnostic & for whom?
- resting arterial brachial index (ABI): portable doppler + sphygmomanometer cuff
- used in pts with 1 or more of:
- exertion leg sx’s
- non healing lower extremity wounds
- hx with PAD in 65 ys +
- sx in pt 50 yrs + with smoking hx or diabetes
ABI interpretation and scores
- ABI lower in affected extremity
- measure brachial artery with dorsals pedis and posterior tibial arteries
- <0.9: PAD
- 0.75 - 0.5: claudication
- < 0.5: rest with pain and/or tissue loss
- 1-1.3: normal
- >1.4: calcified arteries → further assess with toe brachial index
AAA screening
1 time in men 65-75 who ever smoked
PAD treatment/management
- stable claudication
- exercise, no smoking, HTN/HLD/DM tx, compression stockings if ABI > 0.8
- train walk to point of pain the rest til pain subsides
- podiatry consult
- ALL pts get ASA or placid, ACE/ARB, cilostazol (improve walking distance)
- NO b complex vitamin
- if severe ischemia: arteriography (diagnostic), then angioplasty or surgery = refer to er
PAD complications
- AAA!!!
- non healing wounds/ulcers
- peripheral neuropathy
- renal artery stenosis
- infection
pericarditis can be from
- bacterial or viral infection
- autoimmune
- w/ MI
- isoniazid or hydralazine
- malignancy
pericarditis clinical presentation
- sudden onset sharp retrosternal chest pain radiates jaw neck, pleuritic in nature
- chest pain worse supine, relieved sitting up & leaning forward; worse with inspri/expiration
- pericardial friction rub 85% while sitting, leaning forward
- RUB DOES NOT CHANGE WITH INSPIRATION/EXPIRATION
pericarditis diagnostic criteria
2 or more:
- sharp pleuritic chest pain
- diffuse ST elevation
- pericardial friction rub
- new or worse pericardial effusion on ECHO (elevated inflammatory markers)
pericarditis workup
- EKG: diffuse ST elevation
- Send to ED
- CXR (size, r/o pulmonary etiologies)
- ECHO (normal or pericardial effusion)
- CBC w/ diff, ESR/CRP (eleva) troponin (elv)
*pericarditis treatment
- low risk: no large effusion, stable, no fever → outpatient
- NSAIDs (ibuprofen or indomethacin) MAX dose then titrate down over 3-4 weeks
- f/u regularly recheck inflammatory markers and sx’s
- if no improvement in 1 wk, get hospitalized and refer to cardiology for further eval
