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Flashcards in Cardio CIS Handout Deck (32)
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1

Cardiovascular etiologies of chest pain

Acute coronary syndrome (ACS) — unstable angina, NSTEMI, STEMI, pericarditis, pericardial tamponade, aortic dissection, valvular heart disease

2

Pulmonary etiologies of chest pain

PE
Pneumothorax (PTX)
Pleurisy
Asthma exacerbation
COPD exacerbation
Respiratory infection

3

Gastrointestinal etiologies of chest pain

GERD
Esophageal spasm
Esophagitis
Esophageal rupture (Boerhaave)
Hiatal hernia
Pancreatitis

4

MSK etiologies of chest pain

Costochondritis
Rib fracture/contusion
Pectoralis spasm

5

Endocrine etiology of chest pain

Hyperthyroidism

6

Psychiatric and other causes of chest pain

Severe anxiety, panic attacks, cocaine induced vasospasm

Other: sickle cell, rheumatic diseases, sarcoidosis, herpes zoster

7

Possible PE findings in pt with acute coronary syndrome

Hypotension/hypertension

Diaphoresis with cool/clammy skin

JVD

3rd or 4th heart sound

Rales on pulmonary auscultation

8

Most common presentation of acute coronary syndrome

Pressure-type retrosternal chest pain that typically occurs at rest or with minimal exertion lasting >10mins

Can radiate to either or both arms, neck, or jaw

Unexplained new-onset or increased exertional dyspnea is the most common angina equivalent

9

What are atypical presentations of acute coronary syndrome? What patient populations tend to present this way?

Atypical symptoms may include epigastric pain, indigestion, stabbing or pleuritic pain, and increasing dyspnea in the absence of chest pain

Usually older patients, women, diabetics, impaired renal function, and dementia present this way

10

Negative risk factor (i.e., protective) for cardiovascular disease

HDL > 60 mg/dL

11

Risk factors for cardiovascular disease

Increasing age

M>F

Smoking/second-hand smoke

Sedentary lifestyle (need moderate exercise 3x/week)

Obesity (BMI >30 or waist girth >102cm/40in in men and >88cm/30in in women)

HTN (>140/90)

Dyslipidemia (LDL >130 or HDL <40 or TC >200)

Pre-diabetes (IFG >100 or OGTT 140-199)

Psychosocial stress

Family hx

12

Describe stable angina

Intermittent chest pain that can be brought on by exertion or duress

Improves with rest and/or nitro

Episodes tend to be similar in nature and last 2-5 mins

13

Describe unstable angina

Chest pain that can occur at rest, pain tends to escalate over time, episodes last ~10 mins

Does NOT respond to rest or nitro

High risk of adverse event — NSTEMI/STEMI

14

ECG findings and cardiac enzymes with unstable angina

Nonspecific; may have inverted T wave

ECG changes are typically transient

Normal cardiac enzymes

15

What is an NSTEMI and how does it present on ECG and cardiac enzymes?

Complete occlusion of minor coronary artery or partial occlusion of major coronary artery that causes ischemia, tissue damage, and possible myocyte damage/necrosis

EKG findings vary - normal or may have ST depression, T wave inversion

Elevation of cardiac enzymes

16

What is an STEMI and how does it present on ECG and cardiac enzymes?

Complete vascular occlusion of major coronary artery leading to ischemia and myocardial damage/necrosis

ECG: ST elevations affiliated with area of heart where blood flow is affected; may also have new LBBB

Elevated cardiac enzymes, severe symptoms

17

Immediate medication treatment for ACS

MONA-B

Morphine
O2
Nitro
ASA
Beta blocker

18

Labs and tests to order immediately on presentation with ACS

CBC - check for anemia

CMP - check for electrolyte imbalances; liver or kidney dysfunction

Cardiac markers - Troponin (I or T) immediately, then repeat q6h x3

CXR - evaluate for potential causes of chest pain

EKG - immediately, then repeat q8h x3

[consider doing lipid panel later to check for HLD; also consider urine drug screen]

19

What 3 scenarios in pt presenting with ACS warrant STAT cath lab transfer?

Uncontrollable chest pain

New LBBB

STEMI

20

Use of _____________ within 24 hours of presentation is a contraindication to use of NTG

Phosphodiesterase inhibitors (e.g., Sildenafil - Viagra)


[secondary to hypotensive effects d/t systemic vasodilation — can result in severe hypotension or even death]

21

Viscerosomatics for heart and lungs

Heart:
Sympathetic — T1-5
Parasymp — Vagus (CN X)

Lungs:
Sympathetic — T2-7
Parasymp — Vagus (CN X)

22

Pain tolerance may be lowered in pts with ACS due to hyperactivity of sympathetic nervous system. Various OMT techniques may be used to address this, but it is important to be careful in pts with _________

Arrhythmias

23

Anterior chapmans reflexes for myocardium, bronchus, upper lung, lower lung

Myocardium: 2nd ICS @ SB

Bronchus: 2nd ICS @ SB

Upper lung: 3rd ICS @ SB

Lower lung: 4th ICS @ SB

24

Posterior chapmans reflexes for myocardium, bronchus, upper lung, lower lung

Myocardium: intertransverse spaces between T2-3

Bronchus: lateral to T2 spinous process

Upper lung: intertransverse space T2/T3 AND intertransverse space T3/4

Lower lung: intertransverse space T4/T5

25

2 important lymphatics considerations prior to using these techniques in patients with cardiovascular symptoms

Thoracic pump w/ vacuum is CONTRAINDICATED in COPD

In heart failure pts, consider fluid status before treating — can the heart tolerate increased flui return/circulation/stress?

26

Diaphragm vs. bell for auscultation

Diaphragm — high pitched (i.e., S1, S2, AR, MR, friction rubs)

Bell — low pitched (i.e., S3, S4, MS, carotid bruit)

27

Where is the PMI usually palpated?

Near the 4-5th intercostal space in MCL

Should be small, brisk beat and measure <2.5cm; Impulse should last through the first 2/3 of the systolic period (or less) — should NOT be felt through the second heart sound

28

How can you estimate cardiac size when PMI not detectable?

Percussion! Start far left where “resonant” and move medially to find cardiac “dullness”

29

Grading of pulses

0 = absent, not palpable
1 = diminished, barely palpable
2 = average intensity, expected, nml
3 = strong, full, increased
4 = bounding

30

Normal cap refill time

2 seconds or less

31

3 areas to be examined for pitting edema

Dorsum of foot

Anterior tibia

Behind medial malleolus

32

Grading of pitting edema

0= Absent

1+ = barely detectable, slight pitting (2mm); disappears rapidly

2+ = slight indentation (4mm); 10-15 seconds

3+ = deeper indentation (6mm); may be >1 min

4+ = very marked indentation (8mm); 2-5 min


[documented as +0/4 —> +4/4 pitting edema]