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Immediate thoughts when assessing someone with chest pain



what are the 5 questions you want to ask for quality of chest pain?


  • How severe is the pain?
  • Is the pain pleuritic?
  • Is the pain reproducible?
  • Does it radiate?
  • What was patient doing at onset?


Severe pain supports what type of etiology?

What type of pain is considered aortic dissection until proven otherwise?

•Severe pain supports a critical etiology


Tearing, shearing pain radiating to the back is an aortic dissection until proven otherwise – immediate threat to life


Pleuritic Pain (describe this pain ... please)


What do you explore if it is associated with fever, cough SOB?

•Typically sharp, STABBING, unilateral, made worse with effort of deep breath


•If associated with fever, cough, shortness of breath, explore infectious process (pneumonia)


Angina Pectoris

what is this pain from?

what are some charecteristics of the pain?

what dont you forget about with angina pectoris?

•Chest pain due to ischemia of the heart muscle – generally due to obstruction or spasm of the coronary arteries
•Pain characteristics – tightness, constricting type pain, “elephant sitting on my chest”
•problem with angina: atypical presentations   (eg, women, diabetes)


Symptoms of Angina Pectoris (8)







•Band across the chest

•Weight in center of chest


Associated Symptoms of Angina (5)


where can it travel?

when does it happen?

what can cause it?

what makes it better?

Dyspnea – considered an “angina equivalent” and may be the ONLY symptom

Radiation – often radiates (most prevalent spots – left arm, left shoulder)

•Pain occurring with exertion, abating with rest (differentiates it from MI)

Patients often report exacerbating factors emotionally upset, heavy meals, cold weather

•Relieving factors – rest and nitrates


Chronic Stable (3) vs. Unstable Angina (5)


Chronic Stable

•Predictably provoked by exertion

Relieved by rest

•Etiology – chronic stable coronary stenosis



•Occurs with minimal exertion and rest

•Pain is new in onset

•Pain is increasing intensity

•Etiology – associated with ruptured plaques and thrombi, causing obstruction

•Spasms may contribute



“Angina Equivalents”


what are 4 equivalents?

who is more likely to present with equivalents?

•Definition – symptom that a patient has instead of chest pain that may be indicative of CVD, myocardial infarction

•Equivalents – shortness of breath, indigestion, weakness, malaise

Women are much more likely to present without chest pain, but with “equivalents”


if someone says i have been nauseous and jsut not feeling well....wht do we always go




what does it feel like?

how long does it last?

what are aggravating factors: (2)

Risk factors (5)

How is the pain relieved?

Associated symptoms?


Sharper and more tearing than ischemic pain

•Lasts for hours

•Aggravating factors – changing body position (KEY), breathing

•Risk factors – lupus, RA, kidney failure, cancer, trauma (steering wheel to chest)

•Pain is sharp and intense – RELIEVED by leaning forward, worse laying down

•Associated symptoms may include fever, malaise


Key points for Pericarditis

(3 things)


what is this usually caused by?

what might your hear?

what might it mimic?

•History - Recent illness? (typically viral)

•Physical Exam – may reveal friction rub

•Diagnostics – may mimic myocardial infarction on an ECG; ECHO helpful for detecting fluid


How does Pericarditis look on an EKG




looks similar to MI

ST elevation in many leads

Diffuse ST elevation throughout EKG





If they just had viral infection with a fever… leaning forward… and sharp pain on inhalation…and ST elevation on EKG



get and echo and really see it!


Waht is Cardiac Tamponade


what is Beck’s Triad?

  • Cardiac tamponade is a complication of pericarditis
  • Pressure from fluid built up in pericardial sac reaches the point where it restricts blood from returning to the heart


  • Beck’s Triad:
  1. low blood pressure
  2. distended neck veins
  3. muffled heart sounds



Aortic Dissection

how does it feel

where does it radiate

what kind of pain

what can it be confused with


what about the pts vitals?

  • Sudden onset of sharp ripping, tearing pain
  • Typically radiating to the back or felt in the back
  • Pain may be constant or pleuritic
  • Often confused with MI, esophagitis or pericarditis
  • Blood is pooling in the tear… so the patients vitals are decreasing!

  • Pain is usually SUDDEN!



Physical Exam for Aortic Dissection



what is the overall mortality rate for aortic rupture?

what are two outcomes that can comr from this?

  • Loss or delay of radial, femoral, pedal pulses when comparing one side to the other
  • Heart murmur – if it involves the aortic valve
  • If blood vessels exiting the aorta are damaged with dissection, paralysis or stroke may occur
  • Blood supply to bowel, kidneys or extremities may occur
  • Over-all mortality rate for aortic rupture is 80%


Other Causes of Chest Pain (6)

•Pulmonary Emboli

•Esophageal dysfunction, tearing, rupture

•Spine, muscle, nerve

•Rib fracture, costochondritis (these hurt...always palpate)

•Skin – herpes zoster

•Referred pain from abdomen – gallbladder, stomach, pancreas, fluid accumulation (often in geriatric pt)



Ask about Chest Pain


alright so just think of some questions you could ask relating to this!

dont memorize this card silly.... just think about it



•Quality (stabbing, burning, tearing, crushing)

•How long does it last?

•Does it come and go? (intermittent)

•What makes it better?

•What makes it worse?

•Does it radiate? Where?

•Any preceding illness?

•Any trauma?

•Similar episodes in the past?

•Is it different from previous episodes (if patient has had previous episodes)


what about Associated Symptoms with chest pain that you would want to ask your patient if they have (8)?


what are some questions to ask your future patients?

•Palpitations? sustained or intermittent

•Shortness of breath?

  • –Dyspnea
  • –Orthopnea
  • –Paroxysmal nocturnal dyspnea (PND)?

•Swelling or edema? where specifically

•Abdominal, back pain or arm pain?

•Fever or chills?


•Nausea or vomiting?



Ask about Risk Factors for CAD


so what are the risk factors? (5)





•Family history of premature CHD


Ask about Risk Factors for PE (5)

•Recent surgery


•Prolonged inactivity – long flights, bed rest

•Oral contraceptive use

•Cancer diagnosis



Ask about Risk Factors for
Aortic Dissection (6)


•Marfans Syndrome (Abraham Lincoln)

•Ehlers-Danlos Syndrome – extreme laxity of joints

•Polycystic kidney disease


•Cocaine use


Auscultation of the Heart

....sequence of exam....

•Visualize the underlying structures

•Sequence of exam:

  • –Supine with head of bed elevated 30˚
  • –Left lateral decubitus
  • –Sitting, leaning forward


Heart Sounds & Circulation


S1 & S2

what are these noises from? and where are they heard loudest?

what is splitting of S2 mean? when is this heard?

  • As the heart valves close, S1 and S2 heart sounds result (“lub-dub”)
    • S1 results from closure of mitral valve (heard loudest at apex)
    • S2 results from closure of aortic valve (heard loudest at base)
    • Physiology splitting of S2
      • A2 and P2 (heard during inspiration)


Extra Heart sounds

what are they?

what are they correlated with (2)

what are the two sounds caused by?

what words can these sounds be associated with

  • Pathologic extra sounds: S3 and S4
  • Highly correlated with HF and myocardial ischemia
    • S3 (aka S3 “gallop”) caused by abrupt deceleration of inflow across mitral valve
    • S4 caused by increased LV and diastolic stiffness

S3 – sounds like “Kentucky”

S4 – sounds like “Tennessee”


Diaphragm vs. Bell

Which tupe of pitch do you hear with either side?

which heart sounds?

and what valvular conditions?

  • Use DIAPHRAGM to hear…
    • High-pitched sounds of S1 and S2
    • Aortic and mitral regurg
    • Pericardial friction rubs
  • Use BELL to hear…
    • Low-pitched sounds of S3 and S4
    • Mitral stenosis murmur


Heart Murmurs


•Techniques to better hear and identify murmurs: (4)

•Techniques to better hear and identify murmurs:

  • Remember the locations on the chest wall (eg, apex) to help identify the valve where it originates
  • Identify S1 & S2 to determine if murmur is systolic, diastolic or pansystolic
  • Diaphragm vs. Bell
  • Positional changes



Identifying Heart Murmurs : 7 things to look at 



•Location of maximal intensity


•Intensity (grade 1-6)




How do you document a murmur


example of documentation...(just flip the card)


random questions:

where does aortic stenosis radiate

where does mitral regurg radiate

•Document murmur in chart based on its anatomical location (eg, 2nd intercostal space, LSB, base: AORTIC REGURG)


•Example of documentation:

  Heart: high-pitched, grade 2/6, blowing decrescendo diastolic murmur, heard best in the 4th intercostal space, with radiation to the apex

 aoritic regerg






Putting it all together: the physcial exam.

waht do you look for in the systems (6)

•Vital signs – BP, HR, RR, temperature

•O2 sat

•Skin – look for rashes (herpes zoster) or findings indicative of hypercholesterolemia

•Head & Neck – check JVP, listen to carotid arteries for bruits or radiating heart murmurs

•Thorax – palpate for rib or muscle tenderness

•Lungs – listen for crackles, wheeze, rhonchi, decreased breath sounds on inspiration

•Cardiac – listen for S1 and S2 heart sounds and murmurs/rubs/gallops, palpate PMI

•Abdomen – palpate for tenderness or mass, listen for bruits over the aorta

•Extremity/Peripheral vascular – check pulses, check for edema


what could you see on the skin?





Cardiac Biomarkers:

what are 2 of them?

which one is perferred? why?

what is required for diagnosis of AMI

when should you check for troponin?

when do levels increase? when do they peak? when do they return to baseline?

Troponins (gold standard) & CK-MB released with myocardial cell death

•Tropnonin – preferred marker (more specific and sensitive for AMI)

•Elevation in the concentration of troponin or CK-MB is required for the diagnosis of AMI (Am College of Cardiology)

•General approach: check troponin at first presentation, if normal repeat at 4-6 hr, could repeat at 12-24 hr if high level of suspicion

•Troponin levels increase w/n 3-12 hrs from pain onset, peak at 24-48 hrs, return to baseline over 5-14 days



Specifically, cardiac troponins I and T as well as the MB isoenzyme of creatine kinase (CK-MB)



Troponin (2 important concepts to remember)

who is it not necssary for the diagnosis of 

what do we persue even if Troponin labs are pending

•Don’t wait on it – not necessary for diagnosis in patients with ST-segment elevation on ECG and ischemic chest pain

•Don’t delay – pursue thrombolytic therapy or coronary angioplasty if warranted (even when troponins are pending)



what do we want to check if suspect HF

What do we not compare

what is a Caveat with labs and symptomatic/asymptomatic HF patients?

what can be done to guide management of acute HF 

•Check plasma concentrations of brain natriuretic peptide (BNP) and/or N-terminal pro-BNP (NT-proBNP) in patients with suspected HF

Do NOT compare values (different reference ranges, different assays)

•Caveat – not all patients with symptomatic HF have high plasma BNP or NT-proBNP concentrations and not all asymptomatic patients have low values

•Can check serial BNP levels to guide management of acute HF


what are the two conditions you would want to order lipid levels for?


what are the 2 reasons you order lipids?

what are the two different types of test you can order?



GOAL levels for Lipid Panel?

Coronary heart disease (CHD) and related conditions (eg, stroke) are the most common cause of morbidity & mortality in U.S.

Dyslipidemia is typically asymptomatic, but is common and an important predictor of CHD risk

–There are a variety of treatments that are effective in lowering the risk of primary CHD risk


•When to order lipids?

–For screening purposes (primary prevention)

–For monitoring purposes (secondary prevention)


•Choice of tests varies

–Total cholesterol, HDL-C, LDL-C, triglycerides

•Fasting (full lipid panel) vs. non-fasting



dependent on RF now, these protocols have changed now, not specific on numbers! (refer to Dr. Handlers lecture)



Big 3 things You DO NOT Want to Miss when accessing chest pain?

  1. Myocardial Infarction
  2. Pulmonary Embolus
  3. Aortic Dissection


***Consider all 3 of these with every patient presenting with a chief complaint of chest pain!


Red Flags



•Severe, unrelenting sub-sternal pain

•Unstable vital signs

•Associated symptoms of moderate to severe shortness of breath

•General survey reveals diaphoresis, anxiety

•Patient voices feeling of impending doom


Major CVD Risk Factors (8)

  1. •Cigarette smoking
  2. •Poor diet
  3. •Family history of premature CVD
  4. •Hypertension
  5. •Diabetes
  6. •Obesity
  7. •Dyslipidemia
  8. •Physical inactivity


Lifestyle Changes for CVD (7)

•Don’t smoke!

•Optimal weight (BMI 18.5-24.9)

•Low or no added salt in diet

•Regular aerobic exercise

•Moderate alcohol consumption

•Diet rich in fruits, vegetables, low-fat diary, fiber

•Consider referrals – diabetic educator, dietician, others?


Resting EKG

Why is it not great for ruling in or out CAD?

what can look for in a resting EKG (5)

Not the most helpful at ruling in or out CAD….why? cause it is AT REST!!!!
  • Rate
  • Rhythm
  • Axis
  • Hypertrophy
  • Injury/infarct/ischemia


Holter monitor


how long does it monito?

what can the patient do?

who is it useful for?

  • Worn externally
  • Monitor continuous EKG for 24 to 48 hours
  • Patient can “mark” an event of symptoms (They can push a button when they have those symptoms)
  • Useful for patient who is having frequent episodes


Event Monitor

how is it used?

how long does it monitor?

who is it useful in?



  • External “card” or subcutaneously (Just a card placed over the chest)
  • Monitor continuous EKG for weeks
  • Useful for patient who is having sporadic  episodes


Loop Monitor


how long can it monitor for?

where is it places?


Implantable under the skin

Loop monitor monitors for up to several years at a time

very very infrequent


Plain Xrays

can look for heart structures and can showe subtle changes you want to follow up with later


Cardiac enlargement

picture on flip side of it...

but what are the normals for the cardiothoracic ratio? fracton? etc

Cardiothoracic ratio < 0.5:1

2/3 of heart on left. 1/3 on right

No more than ½ thoracic cavity


2/3 heart on left, one third on right

Two thirds of the heart lies on the left side of the chest, with one third on the right. The heart should take up no more than half of the thoracic cavity. The left border of the heart is made up by the left atrium and left ventricle.

The right border is made up by the right atrium alone. Above the right heart border lies the edge of the superior vena cava.






Congestive heart failure


what does it look like on a CXR

Obscuring the heart border, can't tell cardiomegaly


They do have cardiomegaly, can see after fluid is gone


Congestive heart failure

what will you be looking for on the X-ray (5)

  • Pulmonary edema/CHF
    • Interstitial edema
    • Perihilar infiltrates
    • Peribronchial cuffing
    • Cephalization of vessels
    • Kerley B lines


what is going on here

Intersitial edema: Fluid in intertial areas of the lungs


What is a pathological sign to look for with Perihilar infiltrates?

What should you look for with peribronchial cuffing ? and what is peribronchial cuffing?

Perihilar infiltrates, perbronchial cuffing with bilateral pulmonary effusions


Perihilar infiltrates: look for the bat appereance 

Peribronchial cuffing: (look at the picture on the front of this flashcard) On X-ray look at the clear circle: that is air in your bronchus (peribronchial cuffing)


Cephalization of vessels


what is blood resdistributed to?


~Redistribution of blood to upper lobe vessels                          ~Increased pressure of interstitial fluid compresses lower lobe vessels                                   

~recruitment of upper lobe vessels




what are they?

where do you see them?

what do they indicate?

•Short parallel lines at the Lung periphery

•Distended interlobular septa

Kerly B lines: In CHF you will have this!  know this is it on your BOARDS :)



etiology (6)

  • Etiology of calcifications
    • Valve leaflets and rings
    • Coronary arteries
    • Ventricular wall aneurysms
    • Pericardium
    • Thrombi
    • neoplasms


X-Ray limitations (4)

  • Heart may appear Falsely enlarged with XRay
  • during poor inspiration: higher diaphragm
  • with abdominal distension: pregnancy, ascities, etc.
  • Portable (AP) chest films
  • Heart may appear Deceptively small with XRay
  • Over-inflation of lungs: COPD
  • Obscured image
  • Pulmonary effusion
  • Pneumonia
  • Further study:  echocardiogram


okay so tell me what is happening here... compare right image to left image... please

Expiration vs Inspiration

•Poor inspiration (left): loss of right heart border

•Full inspiration (right): Right heart border is visible



compare these AP and PA views?

what does a AP view do?

PA vs AP

•AP view shows magnification of the heart and widening of 

      the mediastinum, shows falsly enlarged heart

•Reserve for patients who cannot stand upright
left xray: PA
Right xray: AP


Obscured border


what is going on here


Over-inflation makes heart look small






is this invasive?

whare are the two types of echos?

can you view it in real time?

what are 6 things you can evaluate with a echo?

  • Ultrasound images of the heart: MINIMALLY INVASIVE
  • Trans-thoracic
  • Clots atrial appendage
  • Can be viewed in “real time”
  • Can evaluate chamber size, wall motion, valve abnormalities
  • Can detect defects between chambers
  • Can detect pericardial effusions
  • Flow patterns:
  • Blue is toward the probe
  • Red is away from probe


Stress Echo


what are three things you you look for on this?

  • Useful to look for functional abnormalities under the stress of exercise
    • Decreased wall motion secondary of ischemia
    • Exacerbation of valvular disorders
    • Decreased ejection fraction


**compare resting and exercise...look for areas that under the stress of exercise start to loose function as listed above**


Standard Stress Testing

what does this reveal? (4 things)

what must you be able to do?

what is it designed to do to patients?

what is the sensitivtiy and specificty?

what about intermidiate patients?

______ higher rate of false positvies in women?

  • Resting EKG: rate, rhythm, axis, hypertrophy, injury/infarct


  • 12 lead EKG under the stress of exercise


  • Screening tool
  • Reveals exercise induced ischemia = Coronary artery disease
  •  Stress induced  cardiac arrhythmias
  • BP response to exercise
  • Patient’s functional capacity


  • Must be able to exercise
  • Various diagnostic protocols designed to take patients to 85% or higher of predicted max HR
  • Overall sensitivity 68%/specificity of  77%
  • Good initial screening for intermediate risk patients
  • 5X higher rate of false positives in women


what's happening in V3 and what would this indicate in a stress test?

this  card is wrong? idk what she was saying I dont see depression in V3?




the ST depression is what you are looking for when you do a stress test


Nuclear Imaging


most common type?

why is it useful? 

  • Myocardial perfusion imaging 
    • technetium (Myoview) stress testing is most common
    • previously Thallium/cardiolite
  • Attracted to functional mitochondria, and accumulates in viable  heart muscle
  • Useful:
  • Resting heart tissue
  • Viable vs non-viable
  • Exercised heart tissue
  • Ischemic vs non ischemic


Nuclear imaging

what are the three orientation views for nuclear imaging ?

Perfusion Images are viewed in three orientations:

SA – Short Axis

VLA – Vertical Long Axis

HLA - Horizontal Long Axis


Nuclear Perfusion Images

  • Rest and Stress images are compared
  • Filling defect at rest = Old MI
  • Filling defect after exercise: =  ischemia
  • In the study below,
  • the rest image indicates normal blood flow
  • stress image indicates abnormal blood flow in the Inferior-lateral region.
  •  This may indicate “ischemia” in this region of the heart – which is supplied by the LCX (left circumflex artery). There may be stenosis in that coronary artery.


If normal at rest and then not with stress: ischemia


whats this

Normal Myocardial Perfusion: no defect comparing rest and stress



whats this

Myocardial Ischemia: note filling defect between rest and stress


whats this

Myocardial Infarction: filling defects with no difference between rest and stress


Nuclear Imaging for disabled or those who can't exercise

  • “Chemical” stress test
  • dobutamine/persantine puts stress on heart
    • Areas lacking perfusion reveal a filling defect where contrast does not perfuse


Nuclear Imaging


what does it evaluate?


  • MUGA (multi-gated acquisition) scan:
    • Evaluates ventricular function, wall motion, and volume (Ejection Fraction) basically...the contractility of the heart
    • Technetium labeled RBCs imaged with Gamma camera



Cardiac MRI


waht kind of pictures?

what can you see?


  • MRI yields anatomic and functional pictures of the heart
  • Can see chamber wall thickness and motion
  • Images possible in numerous selected planes


  Cardiac CT


images during when?

is it fast?

A type of score you do?

what vessels can you get imaged of?


  • Also images during phases of cardiac cycle
  • Excellent resolution, and fast!
  • Coronary artery calcification score: indicative of CAD
  • Images of cardiac vessels


Coronary Angiography

how is it done? 

how are images viewed?


times to remember?

  • Most invasive!
  • The “Gold Standard” to diagnosing coronary heart disease
  • Catheter inserted into femoral artery and advanced to origin of coronary arteries
  • Contrast is injected and images are viewed under fluoroscopy
  • Disadvantage:
    • Risk of bleeding, perforation, contrast
  • Advantage:
    • Can fix what’s broken:  angioplasty and stent

Continuous X-ray

****3 hours since symptoms

******90 min once arriving to hospital

******Cant do anything about CAD with the CT and MRI! So then you have to get angiogram to be able to do something about it! THIS IS WHY IT IS GOLD STANDARD*****


Ankle Brachial Index



what is it most commonly used in?

what is it looking for?

if you hear a _______ what do you do?

what are 3 risk factors for suspecting clot?

  • Non invasive, inexpensive
  • Most commonly used in evaluation of carotids, aorta, and deep veins of lower extremities
  • Looking for DVT (deep vein thrombosis)
  • Clot in peripheral veins
  •  Risks include extended sitting, smoker, birth control pills after age 35
  • Clot can travel to lung and cause Pulmonary embolism

Auscultating the carotids and you hear a bruit… NEXT STEP ULTRASOUND!


what is it

Arterial ultrasound


what is this?

Venous Duplex Ultrasound


Complete blockage of great saphenous vein


on the right ultrasound: venous duplex confirming complete obliteration of the greater saphenous vein (arow) post-ablation


Venous Duplex


what do you attempt to do with this study?

what can you evaluate?

if the vein will not flatten what do you suspect?

  • Ultrasound of deep veins: attempt to compress vessel
  • Color doppler can evaluate flow
  • Numerous views available: need quality sonographer
  • CTA/MRA can also be used, but question cost vs additional benefit over US


Can look at flow and compressibility

If a clot the vein will not flatten: THROMBOSIS




what are these

what dimensions

what to remember about CTA

what is it useful in diagnosing


Two dimensional and three dimensional imaging


MRA: contrast free

CTA: ionizing radiation, available, and fast




Useful in diagnosis of Abdominal aortic aneurysms (AAA) and aortic dissection


AAA and Aortic Dissection

how are they found?

are they dangerous?

what imaging should we use to view these?

  • AAA
  • Typically found as pulsatile mass on exam
  • Can leak or rupture out: medical                            emergency
  • CT best if suspect leak
  • Aortic dissection
  • Typically a “tearing pain”  in chest, radiating to back
  • Can quickly be fatal
  • CT: faster evaluation but need contrast
  • MRI: longer wait time but no contrast


Vascular angiography


how is it done?

what can you view?

what is digital subtraction angiography?

  • Invasive: catheter inserted into chosen vessel and contrast injected
    • Can view most arteries: common to study heart, renal, aorta, carotids, periphery for vascular disease
  • Digital subtraction angiography: digitally reduce background “noise” of other images


Precordial lead placement

V1: 4th intercostal space right of sternum

V2: 4th intercostal space left of sternum

V3: between V2 and V4

V4: midclavivular line in 5th intercostal space

V5: between V4 and V6

V6: midaxillary line in 5th intercostal space


what is the most common cause of morbidity and mortality in the US?

coronary heart disease CHD and its related conditions


which leads show ST Elevation in pericarditis?

ALL of the leads!!! (hoffman)


(Handler) initally see ST elevation in all leads except V1 and AVR 


T wave flattening and T wave inverion later on


anyone in afib should get...

a TEE because it allows you to see the heart better and evalulate for clots better than transthoracic echo