Chest pain Flashcards
What RF can increase atherosclerosis
- cocaine
- HIV
classic presentation of CP
- Retrosternal in L anterior chest
- Crushing, tightness, squeezing, or pressure
- Worsened w/ exertion
- Alleviated w/ rest
- Dyspnea, diaphoresis, nausea
- Radiation to L shoulder, jaw, arm, or hand
onsets of classic chest pain presentations
Sudden or gradual:
* Angina: 2-10 min
* Unstable angina: 10-30 min
* AMI pain: >30 min
Two categories of ”chest pain” based on nerve fiber:
- Visceral:
- Located in heart, blood vessels, esophagus, and visceral pleura
- Pain difficult to describe and localize
- Discomfort, heaviness, pressure, tightness, aching
- Pain can radiate - Somatic:
- Innervates chest wall, from dermis to parietal pleura
- Easily described and precisely located
- Sharp, stabbing, scratchy, without radiation
atypical CP presentation can be seen in who?
- Pre & early menopausal women
- Racial minorities
- DM
- Elderly
- Pts w/ psychiatric disease or AMS
If any of these sx are present, it is unlikely an AMI:
- pleuritic in nature
- Positional
- sharp
- reproducible with palpation/positioning
Possible PE findings for cardiac CP
- Tachycardia - ↑ sympathetic tone, ↓ LV stroke volume
- Bradycardia - ischemia to conduction system
- Acute ischemia -
- 3rd/4th HS from changes in ventricular compliance
- new murmur from ruptured cordae tendineae
- aortic root dissection, or crackles on lung auscultation from CHF. - Chest wall tenderness in 15% of pts, unlikely to be useful by itself to exclude ACS
perform an EKG within ___ min if concern for myocardial ischemia
10
ECG findings of acute MI
tx?
new ST elevations ≥1 mm in two contiguous leads
rapid reperfusion interventions
ECG findings of ____ indicate ischemia → further eval
New ST elevations, Q waves, LBBB, T-wave inversions or normalizations in sx pts
CXR of classic CP presentation
nml MC
r/o thoracic aortic aneurysm, aortic dissection, pneumonia, pneumothorax, PE
next imaging choice after CXR?
r/o for what dx?
Non-contrast CT
PNA, pneumothorax
imaging modility for aortic aneurysm/dissection or PE
Chest CTA
ECHO Emergent may be useful with what severe dx?
- aortic dissection, cardiac tamponade, new regurg murmur
- This will vary on the hospital and staff/providers available
Other tests based on suspected DDx for chest pain
- CBC
- BMP or CMP
- PT/PTT
- ABG
- Type and Crossmatch
- Hcg in women of childbearing age
Best serum marker for myocardial injury
Troponin
AMI troponin measurements (onset, peak, elevated)
- Onset: 4 hours after onset of acute MI
- More reliable 6 hr after sx. - Peak: 24-48 h
- Elevated: 10 d
which serum marker
- useful if timing of infarction remains unclear
- used only if troponin isn’t available or if pt has had an MI in the last 2-3 days
- levels normalize in 48-72 hrs
CK-MB
Red flags during initial triage for chest pain
- Abnormal vital signs
- Concerning EKG findings (if already performed)
- Hx prior CAD
- Multiple ASCVD risk factors
- Advanced age, HTN, tobacco use, HLD, DM, obesity, family hx, ASCVD, sedentary lifestyle - Abrupt onset, new or severe chest pain or dyspnea
Hx for initial chest pain triage
- Should be FOCUSED!
- Include sx and the 7 attributes
- Focused PMH
- Assess for risk factors
- ROS - focused on DDx
sudden, pleuritic CP, focal chest w/ dyspnea, tachypnea, tachycardia, or hypoxemia.
what ddx
Pulmonary Embolism
RF for Pulmonary Embolism
prolonged immobilization, active cancer, recent surgery/trauma, procoagulant syndromes, exogenous estrogen, or previous thromboembolic disease.
Criterias used for PE
Wells, Revised Geneva Scores, PERC
diagnostics for PE
D-dimer
CT pulm angiography
- sudden, severe, tearing pain radiating to scapula; midline, substernal
- Secondary sx - ischemic stroke, AMI, limb ischemia; unilateral pulse deficits or focal neuro deficits
aortic dissection
RF aortic dissection
male, >50y, uncontrolled HTN, CTD, cocaine, bicuspid valve or AV replacement, pregnancy
dx aortic dissection?
CT aortogram / TEE
Nml CXR and (-) D-dimer does NOT r/o dissection
nonspecific ST or T-wave changes on ECG possible
- sudden, sharp substernal CP after episode of forceful vomiting; ill appearing w/ tachycardia, F, dyspnea, and diaphoresis
- Crepitus in neck/chest from SQ emphysema
Esophageal Rupture (Boerhaave’s Syndrome)
what is Hamman’s crunch
crepitus on cardiac auscultation
diagnostic for Esophageal Rupture (Boerhaave’s Syndrome)
- CT of chest w/ oral water-soluble contrast
- Nml or pleural effusion (left MC), pneumothorax, pneumomediastinum, pneumoperitoneum, or subcutaneous air.
esophageal rupture most often in the _____ of the esophagus, resulting in a _____
distal ⅓ of the esophagus resulting in a pneumomediastinum
tx esophageal rupture
- Stabilize air way
- NPO, IV fluids
- Broad spectrum IV antibiotics
- 1st line: ampicillin/sulbactam or pip/taz
- BL allergy: clindamycin + ciprofloxacin - NG or OG tube placement - prevent further saliva and gastric content contamination
- Consult surgery
sudden, sharp, pleuritic CP w/ dyspnea; ↓ breath sounds on affected side
MC tall, slender male pts
Spontaneous Pneumothorax
RF: smoking, COPD, and asthma
Dx: CXR
sharp, severe, constant, and retrosternal that radiates to back, neck, or jaw; worsened supine, relieved sitting forward; pericardial friction rub
Acute Pericarditis
ECG shows PR depressions, diffuse ST-segment elevations, or T-wave inversions; diffused
what dx?
Acute Pericarditis
CP worsened w/ movement of chest and palpation; CP d/t irritation/inflammation
MSK Causes
- Causes: costochondritis, xiphodynia, precordial catch syndrome, intercostal strain d/t coughing, pectoralis muscle strain w/ recent physical exertion.
- Clear MSK etiology + completely reproducible pain w/o other sx or RF
s/s of GI causes of CP
- Gastritis: gnawing / burning pain in lower chest
- PUD: postprandial dull, boring pain in epigastric region
- Esophageal spasm: reflux disease; sudden onset of dull or tight substernal chest pain; precipitated by drinking cold liquids and can be relieved by NTG
initial management for chest pain
- Placed in a treatment bed quickly
- Cardiac monitoring and IV access (2 large bore)
- EKG (within 10 minutes)
- Measure vital signs, then resuscitate as needed, following the ABCs
- supplemental O2 if O2 saturation at rest is < 95%*
for chest pain presentation; admit if they meet this criteria:
- Positive cardiac enzymes
- New concerning EKG changes
- Persistent pain
- Concerning physical exam findings
Heart Scoring
0-3 = DC
4-6 = Admit to observe
7-10 = early invasive strategies
MC sx of ACS
-
MC Chest pain
- substernal or left-sided CP,
- radiation to one or both arms, accompanied with N/V, diaphoresis.
- “Pressure”
- Exertional - Pallor, diaphoresis, AMS, elevated JVD, peripheral edema, or rales
atypical sx for ACS
SOB, N, diaphoresis, back pain, abd pain, dizziness, palpitations
RF for CAD
older, male, FHx, smoking, HTN, hypercholesterolemia, DM, cocaine
presentation of unstable angina
CP (or atypical ACS sx) + obstructive CAD and has one of the following:
- began within past 2 months
- has increasing frequency, intensity, or duration of existing angina sx
- existing angina begins to occur at rest
Dx ACS
cTn, CBC, lytes, PT/PTT, CXR
goals for care in ACS
- reperfusion by reducing thrombus
- limiting thrombus extension
- relieving obstructive CAD
tx options for STEMI
systemic thrombolytic 30 min of arrival / PCI 90 min
PCI preferred - greater benefits and fewer risks if no CI to thrombolysis who can achieve PCI within 120 min.
If no PCI is available, what do you use
fibrinolytics IF:
- < 6-12 hrs of sx onset
- ECG 1 mm ST elevation in 2 contiguous leads
- Full dose anticoag for 48 hrs
- Avoid: arterial puncture, venipuncture, central lines in areas which are not readily compressible
tx for suspected ACS
- cardiac monitoring, IV line, O2 if < 95%.
- ASA 160-325 mg PO chewed; Alt: Clopidogrel
- NTG PO, transdermal, or IV to treat any ongoing angina.
- Morphine if pain continues despite NTG.
- Metoprolol in first 24h
- +/- antiplatelet
- Dual therapy: clopidogrel w/ ASA
- Antithrombin: heparin/enoxaparin
which med recommended for use along with aspirin in pts w/ mod-high risk NSTEMI and STEMI, and in all pts in whom PCI is planned?
Clopidogrel
Hold 5 d before CABG - ↑ risk of bleeding
which anticoag options for use in unstable angina or NSTEMI pts?
- LMWH - Can be used in PCI revascularization
- Unfractionated heparin - CABG
- Factor Xa inhibitor - fondaparinux - Similar efficacy to unfractionated; Good for renal impaired
- Direct thrombin inhibitor - Bivalirudin - Less bleeding and no dosage adjustment in renal impairment ; Alt in STEMI to unfractionated and GP IIb/IIIa inhibitor
tx STEMI
immediate cath
tx for CP treated Thrombolytics but still hemodynamic instability and pain / have not reperfused
rescue angioplasty
Emergent CABG may also be indicated for some patients.
tx for Refractory cardiogenic shock
emergent angioplasty
Other: Intraaortic balloon pump or other LVADs
Admitted to critical care unit
tx NSTEMI or unstable angina w/ ongoing CP, ECG changes, dysrhythmias, or hemodynamic compromise
admitted in cardiac ICU
tx for Unstable angina but no/resolved s/s
admitted to monitored inpatient bed
thrombolytic options
- tPA
- Reteplase (rPA) - Pro: double bolus rather than continuous infusion
- Tenecteplase (TNK) - alt for tPA
-
Streptokinase (SK)
- Can cause allergic reaction
- CI: HoTN, prior SK within 6 mo, strep within year
- Start heparin within 4 hrs of starting SK
complications for thrombolytics?
tx?
bleeding/intracranial hemorrhage
- DC thrombolytics, heparin, ASA
- Crystalloid and RBC infusion possible
- Cryoprecipitate + FFP
-
10 U cryoprecipitate and get fibrinogen levels
- < 1 g/L - +10 U
- Still Bleeding but >1 g/L or < 1 g/L after 20 U → 2 U FFP
- Bleed continues → platelets / antifibrinolytic (aminocaproic acid or tranexamic acid)