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LMCC Part II > Chest Pain/MI > Flashcards

Chest Pain/MI Flashcards

1
Q

what are the most likely etiologies of CP

A

CENTRAL

  1. cardiovascular–25% overall, 50% in older adults
  2. pulmonary/mediastinal–5%
  3. other–30%
    - -GI 20%
    - -neuropsychiatric–10%

PERIPHERAL

  1. chest wall pain–35%
  2. pulmonary–5%
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2
Q

what are the cardiovascular ischemic causes of CP

A

MI–> less than 2% in primary care (acute, evolving, recent, established

angina pectoris

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3
Q

what are the cardiovascular non-ischemic causes of CP

A

aortic aneurysm –dilating/dissecting (consider in HTN, cystic necrosis, marfan’s)

pericarditis –infectious, post MI, post CABG, uremic, connective tissue disease

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4
Q

what are the pulmonary/mediastinal central causes of CP

A

PE
tracheitis
mediastinal malignancy

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5
Q

what are the central GI causes of CP

A 
esophageal spasm
esophagitis/PUD
mallory weiss
biliary disease
pancreatitis
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6
Q

what are the central neuropsychiatric causes of CP

A

cardiac neurosis
anxiety
depression
somatoform

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7
Q

what cause chest wall CP

A

costochondritis

herpes zoster

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8
Q

what are the peripheral pulmonary causes of CP

A

pleuritis
pneumo
pulmonary infarct
malignancy

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9
Q

what are the five deadly causes of CP (mnemonic)

A

TAPUM

Tension pneumo
Aortic dissection
PE
Unstable angina
MI
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10
Q

what is the ACS spectrum

A

stable angina–> unstable angina–> NSTEMI–> STEMI

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11
Q

what is an MI

A

death of myocardial tissue from a relative or absolute insufficiency of blood supply

usually result of coronary artery thrombosis with myocardial necrosis 3-6 hours after onset (or less if sudden, complete occlusion and no collateral flow)

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12
Q

how soon after coronary occlusion with myocardial death occur

A

3-6 hours (or sooner)

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13
Q

other than coronary occlusion, what can cause an MI

A

cocaine

aortic dissection

malignant HTN

hypotension

anemia

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14
Q

what is unstable angina

A

angina pectoris which has recently changed in frequency, duration, intensity or occurs at rest

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15
Q

what is the typical MI presenting CP

A

crushing/squeezing retrosternal chest pain or pressure that radiates to neck/jaw/shoulder/arms associated with nausea, vomiting, diaphoresis, sense of impending doom

may be likened to heartburn

may be like typical angina only more severe and persistent, not relieved by nitroglycerin

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16
Q

how might MI pain differ in someone with DM

A

can be atypical or painless

  • can also be this way in women, the elderly
    i. e can present like CHF, confusion, dizziness, syncope, stroke, new arrhythmia
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17
Q

what are cardiac RFs

A 
previous CAD
HTN
DM
smoking 
family history (first degree relative younger than 55 with first MI)
DLD
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18
Q

what are you looking for on physical exam with MI

A

distress
cold, moist, pale
increased or decreased HR
hypotensive

may have faint heart sounds
S4 is usually present
new MR murmur

may have signs of CHF, including S3, crackles, elevated JVP

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19
Q

what investigations should you order for suspected MI

A

ECG–look for classic stepwise progression and “thrombolytic criteria”

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20
Q

what is the classic stepwise progression of MI on ECG

A

hyperacute T waves–> elevated ST segments with or without reciprocal ST segment depression–> inverted T waves–> may get Q waves

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21
Q

what are the thrombolytic criteria on ECG for MI

A

at least 1mm ST segment elevation in 2+ contiguous leads or new LBBB

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22
Q

what region is the MI in, if the ST elevation is in…?

V1 and V2

A

septal

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23
Q

what region is the MI in, if the ST elevation is in…?

I, aVL, V5, V6

A

lateral

24
Q

what region is the MI in, if the ST elevation is in…?

V3 and V4

A

anterior

25
Q

what region is the MI in, if the ST elevation is in…?

II, III, aVF

A

inferior

if inferior pattern, look for right venticular involvement with right sided leads looking for ST segment elevation in V4

26
Q

what region is the MI in, if the ST elevation is in…?

ST depression in V1-V4

A

posterior

27
Q

what is on the differential when you see ST elevation on an ECG

A
  1. normal variant/early repolarization
  2. ischemic heart disease
  3. acute pericarditis
  4. other causes–LVH, LBBB, advanced hyerkalemia, hypothermia
28
Q

how does normal variant/early repolarization ST elevation look on ECG

A

usually conCAVE upwards ending wiht symmetrical, large, upright T waves

29
Q

how does ischemic heart disease ST elevation look on ECG

A

usually conVEX upwards, or straightened
–“tombstoning”

represents acute transmural injury

persistent ST elevation after acute MI suggests ventricular aneurysm

ST elevation may also be seen as a manifestation of Prinzmetals (variant) angina–> coronary artery spasm

30
Q

how does acute pericarditis ST elevation look on ECG

A

conCAVE upwards in MOST leads except aVR

NO reciprocal ST segment depression (except in aVR)

unlike early repolarization, T waves are usually low amplitude, and heart rate is usually increased

may see PR segment depression, a manifestation of atrial injury

31
Q

how does LVH ST elevation look on ECG

A

in right precordial leads with large S waves

32
Q

how does LBBB St elevation look on ECG

A

in right precordial leads with large S waves

33
Q

how does hypothermia ST elevation look on ECG

A

prominent J waves or Osborne waves

34
Q

what is the ddx for ST segment depression

A
  1. normal variants or artifacts
    - -ie wandering baseline due to poor electrode to skin contact, physiologic J juntional depression with sinus tachy, hyperventilation induced
  2. ischemic heart disease
  3. NSTEMI
  4. reciprocal changes in acute STEMI
  5. non ischemic causes
35
Q

how does ischemic heart disease ST depression look on ECG

A

represents subendocardial ischemia i.e exercise induced or from angina attack

ST segment depression is often described as “horizontal,” “upsloping” or “downsloping”
–> “upsloping” ST depression is not an ischemic abnormality

36
Q

where might you get ST depression in an acute inferior MI

A

leads I and aVL

37
Q

what are some non ischemic causes of ST depression

A

RVH or LVH (right or left precordial leads)

digoxin effect on ECG

hypokalemia

secondary ST segment changes with IV conduction abnormalities

38
Q

what blood work do you order in suspected MI

A

routine BW–CBC, lytes, Cr, urea and troponin q6H x2

consider CK

imaging is CXR to r/o other causes and look for complications

39
Q

what is the immediate management of MI

A

ABCs

initial therapy: MONA BE
morphine
oxygen
nitro
ASA
Beta blocker (if can tolerate)
Enoxaparin/LMWH (if normal Cr)
40
Q

how do you assess ABCs in MI patient

A

A–airway patent? patient talking? thyro-mental distance, malampati score, GCS score

B–oxygen, auscultate for air entry, r/o pneumothorax, Killip score for pulmonary edema, CXR

C–pulses bilaterally, IV access, fluid status, JVP, cardiac monitoring

41
Q

what is the pneumonic for initial MI management

A

MONA BE

Morphine
oxygen
nitro
ASA
beta bockers
enoxaparin/heparin
--also clopidogrel
42
Q

when are beta blockers contraindicated in MI management

A

CHF
bradycardia
hypotension

43
Q

why do we use beta blockers in MI management

A

prevents v fib and cardiac rupture which leads to reduced mortality

44
Q

what do we use to reduce pain in acute MI

A

nitroglycerin S/L q5min x 3 unless hypotensive

morphine/fentanyl

IV nitro–> improves coronary blood flow reduces afterload if CHF/HTN and relieves spasm

45
Q

dose of ASA to give in acute MI

A

325 mg to chew

46
Q

why do we use LMWH in acute MI

A

decreases incidence of early reocclusion after thrombolytic

47
Q

other than the MONA BE meds, what other meds should you consider in acute MI management

A

clopidogrel

ACEi–> especially if anterior infarct without hypotension as it decreases afterload and limit ventricular remodeling

48
Q

what should you give to a patient with RV infarct and hypotension

A

fluid

or inotropes (dopamine, dobutamine) and monitor CVP with central line

49
Q

how do you decide between thrombolytics and immediate angioplasty for open occluded artery

A

if facilities are available or there is a contraindication to thrombolytics then do immediate angioplasty

thrombolytics preserve myocardium and function, reduce mortality and decreases incidence of complications

50
Q

how do you manage an open occluded artery in MI

A

reperfusion therapy with either primary percutaneous intervention (PCI) or, if less than 12 hours has elapsed from onset of symptoms, do fibrinolysis

51
Q

how do you select patients from thrombolysis

A

less than 6 hours from pain onset: ST segment elevation in 2 contiguous leads

52
Q

what are contraindications from thrombolytics

A 
aortic dissection
acute pericarditis 
less than 2 weeks from major surgery or trauma
ICH or trauma
BP above 200/120
active internal bleeding
prolonged or traumatic CPD
prolierative retinopathy or other hemorrhagic ophtho conditions

*always weigh ischemic risks (TIMI score) with bleeding risk

53
Q

after acute initial management for MI what do you do

A

transfer to CCU or ICU

angiogram if not done earlier

  • -ECHO
  • -stress test for stable angina

follow troponin, CK, check glycemic and lipid profiles

cardiac lifestyle teachings especially smoking cessation, cardiac rehab, control HTN, DM, DLD

54
Q

order of administration of meds and interventions in acute MI

A
  1. oxygen by mask or nasal cannular
  2. ASA 160-325 mg chewable
  3. nitroglycerin 0.4 mg SL (can repeat if well tolerated)
    - -can also give nitroglycerin 5-10ug/min IV if chest pain recurs or persists
    1. Metoprolol 5 mg IV q5min x3
  5. morphine 2-4 mg IV bolus
    - -increments of 2-4 mg repeated every 5-10 minutes until the pain is relieved or no more is tolerated
55
Q

in which patients should nitrates be avoided

A

RV infarct
patient is on viagra or another PDE5 inhibitor
hypotension

56
Q

clopidogrel loading dose

A

300-600 mg followed by 75 mg daily maintenance dose

57
Q

management of STEMI per edmonton manual

A 
O2
morphine
ASA
Plavix
LMWH
beta blocker
ACEi
nitroglycerin 
high dose statin

revascularize within 12h of onset of chest pain with PCI
thrombolyse if PCI unavailable for more than 2 hours

LMCC Part II (52 decks)

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