Chest Pain Flashcards
(110 cards)
1
Q
CHEST PAIN
A
One of the most common reasons for ER or OPD
consult.
2
Q
THREE MAIN CATEGORIES OF NON-TRAUMATIC
CHEST DISCOMFORT
A
1. Myocardial Ischemia (Acute Coronary Syndromes) 2. Cardiopulmonary Causes (Pericardial diseases, aortic emergencies, and pulmonary conditions) 3. Non-cardiopulmonary Causes
3
Q
GIT, MUSCULOSKELETAL AND CHEST WALL
SYNDROME-
A
predominates causes of nontraumatic chest pain/ non-cardiopulmonary
causes of chest pain
● However it is imperative to accurately rule out
cardiopulmonary causes for they carry higher
morbidity and mortality than other causes of chest
pain
4
Q
unrecognized or missed diagnosis of MI
A
2-6%
5
Q
Missed diagnosis of MI carries a poor outcome
A
30-day risk of death
6
Q
HISTORY
A
- HISTORY
- PHYSICAL EXAMINATION
- DIAGNOSTIC AND ANCILLARY
PROCEDURES
7
Q
SOCRATES
A
Site, Onset, Character, Radiation, Associated symptoms, TIme, Exacerbating/Releiving, Severuty
8
Q
PLEURITIC
A
for the Respiratory and
Musculoskeletal, it may Be exacerbated by Movement or Inspiration
9
Q
CARDIAC
ISCHEMIA
A
Central
Substernal
Dull
Heavy
Jaw
Neck
Arms
10
Q
RESPIRATORY
A
Localized
Central
(Asthma Or COPD)
Sharp
Pleuritic
Localized
11
Q
MUSCULO
-SKELETAL
A
Localized to the site of Pathology Sharp Pleuritic Band-like/ Shooting Pain (Nerve Root) Around the Chest Wall (Nerve Root)
12
Q
PUD/GERD
A
Lower chest, Epigastric area
Sharp, Burning
Epigastric Area to the Back Pancreatitis
13
Q
EXERTION
A
Cardiac Ischemia
14
Q
DEEP INSPIRATION
A
Respiratory,
Musculoskeletal,
Pericarditis
15
Q
MOVEMENT
A
Musculoskeletal
16
Q
EATING
A
PED/GERD
17
Q
POSITION
A
Pericarditis, Pancreatitis, GERD
18
Q
REST
A
Cardiac Ischemia
19
Q
SUBLINGUAL
NITRATES
A
Cardiac Ischemia
Oesophageal Spasm
20
Q
ANTACID
A
PUD
GERD
21
Q
ANALGESICS
A
Musculoskeletal
Pericarditis
Respiratory
22
Q
PAST MEDICAL HISTORY
A
It is important to determine an accurate past
medical history because this can help us elicit risk
factors for certain diseases, particularly risk
factors for cardiovascular diseases.
23
Q
Cardiovascular risk factors
A
○ Hypertension
○ Diabetes mellitus
○ Dyslipidemia
24
Q
Marfan Syndrome
A
○ Acute Aortic Syndrome
○ Spontaneous Pneumothorax
25
Thrombotic risk factors
○ Malignancy
○ Thrombophilia
○ Recent surgery
26
Premature CAD
Coronary artery disease
| occurring in women and men younger than 55 and 45, respectively
27
PHYSICAL EXAMINATION
● Give clues on the clinical stability of the patient.
● You can triage which of this patients complaining
of chest pain should receive an urgent evaluation
● Can provide direct evidence of specific etiologies
of chest pain e.g., unilateral absence of lung
sounds
● Help identify potential precipitants of acute
cardiopulmonary causes of chest pain. e.g.,
uncontrolled hypertension predisposes to Aortic
Dissection or Acute Myocardial Infarction
● Relevant comorbid conditions (e.g., COPD) and
complications of the presenting syndrome (e.g.,
heart failure).
● A normal P.E. would not mean that there is no
cardiac ischemia e.g.
○ In some cases of unstable angina, the
patient still has normal PE.
28
Cold sweat
sign of heart attack
29
Patients with acute MI or other acute
| cardiopulmonary disorders often appear
anxious,
| uncomfortable, pale, cyanotic, or diaphoretic.
30
Patients who are massaging or clutching their
chests may describe their pain with a clenched
fist held against the sternum
(Levine’s sign
31
Occasionally, body habitus is helpful
```
e.g., in
patients with Marfan syndrome or the prototypical
young, tall, thin man with spontaneous
pneumothorax.
○ Patients with Marfan’s syndrome are at
risk for Acute Aortic emergencies or
spontaneous pneumothorax. So a
general survey may reveal findings that
may be consistent with Marfan’s
syndrome
```
32
VITAL SIGNS
○ Acute MI with Cardiogenic Shock
○ Massive Pulmonary Embolism
○ Pericarditis with Tamponade
○ Tension Pneumothorax
33
ACUTE AORTIC EMERGENCIES
Usually present with severe hypertension but may be associated with profound hypotension when there is coronary arterial compromise or dissection into the pericardium
34
SINUS TACHYCARDIA
● First manifestation
● Important manifestation of submassive
pulmonary embolism
35
PULMONARY CAUSE
Tachypnea and hypoxemia point toward a pulmonary cause
36
FEVER
he presence of low-grade fever is nonspecific
because it may occur with MI and with
thromboembolism in addition to infection
37
PULMONARY EXAMINATION
```
May localize a primary pulmonary cause of chest discomfort.
○ Pneumonia
○ Asthma
○ Pneumothorax
○ Left ventricular dysfunction from severe
ischemia/infarction as well as acute
valvular complications of MI or aortic
dissection can lead to pulmonary edema,
which is an indicator of high risk
```
38
Pulmonary Edema
may be suggested of left
ventricular dysfunction, acute valvular
dysfunction
39
CARDIAC PE
● JVP (useful in checking for right-sided heart failure)
● The jugular venous pulse is often normal in patients with acute myocardial ischemia but may reveal characteristic patterns with:
○ Pericardial tamponade
○ Acute right ventricular dysfunction
40
Cardiac auscultation may reveal S3 or S4
reflecting myocardial systolic or diastolic
| dysfunction.
41
Mitral regurgitation or ventricular septal defect
mechanical complications of STEMI.
42
The murmur of aortic insufficiency
complication of
| proximal aortic dissection
43
Other murmurs may reveal underlying cardiac
| disorders contributory to ischemia
e.g., aortic
| stenosis or hypertrophic cardiomyopathy
44
Pericardial friction rubs
Reflect pericardial inflammation;
| ○ It May be heard in a patient with pericarditis as the cause of chest pain
45
ABDOMINAL PE
```
● Localizing tenderness is useful in identifying a
gastrointestinal cause of the presenting
syndrome
○ However, sometimes the Right Upper
Quadrant tenderness is observed in
patients with severe right ventricular
dysfunction due to hepatic congestion.
```
46
Abdominal findings are infrequent with
purely
acute cardiopulmonary problems, except in the
case of underlying chronic cardiopulmonary
disease or severe right ventricular dysfunction
leading to hepatic congestion
47
VASCULAR PE
Pulse deficits - reflect underlying chronic
atherosclerosis which increases the likelihood of
coronary artery disease.
● Loss of the pulse and pallor - evidence of acute
limb ischemia, particularly in the upper
extremities; can indicate consequences of aortic
dissection
● Unilateral lower extremity swelling-venous
thromboembolism
48
MUSCULOSKELETAL PE
● Pain arising from the costochondral and
chondrosternal articulations may be associated
with localized swelling, redness, or marked
localized tenderness.
● Although palpation of the chest wall often elicits
pain in patients with various musculoskeletal
conditions, chest wall tenderness does not
exclude myocardial ischemia.
●
49
Cervical disk disease-
Sensory deficits in the upper extremities
50
MYOCARDIAL ISCHEMIA
● Myocardial ischemia causing chest discomfort，
termed angina pectoris, is a primary clinical
concern in patients presenting with chest
symptoms.
● Myocardial ischemia is precipitated by an imbalance between myocardial oxygen requirements and myocardial oxygen supply, resulting in insufficient delivery of oxygen to meet the heart's
51
Factors that increase myocardial contractility,
| heart rate, ventricular wall stress increases the
myocardial oxygen consumption.
52
When myocardial ischemia is sufficiently severe
| and prolonged in duration (as little as 20 min)
irreversible cellular injury occurs, resulting in MI.
53
The afferent fibers traverse the nerves that connect to the upper five thoracic sympathetic ganglia and upper five distal thoracic roots of the spinal cord
impulses are transmitted
| to the thalamus eliciting pain
54
Within the spinal cord, cardiac sympathetic
afferent impulses may converge with impulses
from somatic thoracic structures, and this
convergence may be the basis for
referred
| cardiac pain.
55
ISCHEMIC HEART DISEASE
Ischemic heart disease is most commonly caused
by atheromatous plaque that obstructs one or
more of the epicardial coronary arteries. Starts
with fatty deposits and the growth of the plaque
obstructs the blood flow. Symptoms are noted
depending on the degree of blockage.
56
Stable Angina
results from the gradual
atherosclerotic narrowing of the coronary
arteries. It is characterized by ischemic episodes
that are typically precipitated by a superimposed
increase in oxygen demand during physical
exertion and relieved upon resting
57
Unstable ischemic heart disease
ccurs when
rupture or erosion of one or more atherosclerotic
lesions triggers coronary thrombosis.
● It is classified clinically by the presence or
absence of detectable myocardial injury and the
presence or absence of ST-segment elevation on
the patient’s electrocardiogram (ECG)
58
Coronary atherothrombosis
is marked by
ischemic symptoms at rest, with minimal activity,
or in an accelerating pattern.
59
unstable ischemic heart disease is classified as
| unstable angina when
there is no detectable
| myocardial injury
60
When acute coronary atherothrombosis occurs,
the intracoronary thrombus may be partially
obstructive, generally leading to myocardial
ischemia in the absence of
ST-segment
elevation
Read Black Table
61
PERICARDITIS
● Visceral surface and most of the parietal surface
of the pericardium are insensitive to pain.
● What causes the pain of pericarditis is the
associated pleural inflammation
● This pleural inflammation can also explain the
Pleuritic pain that is exacerbated by breathing,
coughing or changes in position noted in
pericarditis.
62
Neck and Shoulder Referred pain
Overlapping sensory
supply of central diaphragm (phrenic nerve) with
Somatic Sensory Fibers from the 3rd to 5th
cervical segments
63
Upper abdomen referred to pain
-Involvement of pleural
the surface of the lateral diaphragm will then explain
the pain of pericarditis that is referred at the upper
abdomen
64
ACUTE AORTIC DISSECTION
● Less common cause of chest discomfort
● Catastrophic Natural History if recognized late
and if untreated
● Involves a tear in the aortic intima -> separation of the media -> creation of a separate lumen (false lumen). If this lumen ruptures it may lead to
catastrophic diseases or death because of bleeding and hypotension also.
65
ACUTE AORTIC SYNDROME
● Severe, sudden in onset, and sometimes
| described as ―”tearing” in quality.
66
Ascending aorta -
pain in the midline of the
| anterior chest.
67
Descending aortic syndromes
pain in the back
68
Myocardial Infarction in AAS
compromise of the
| aortic Ostia of the coronary arteries
69
Acute aortic insufficiency
disruption of
| the aortic valve
70
Pericardial tamponade
rupture of the
| hematoma into the pericardial space
71
Pulmonary - Vascular Conditions
● Pleuritic chest pain
| ○ Pulmonary Embolism
72
PULMONARY EMBOLISM
● Pleuritic in pattern
● Clinical features depend on size
● Massive pulmonary emboli may cause severe
● substernal pain that may mimic MI.
● Massive or submassive pulmonary embolism may also be associated with syncope, hypotension, and signs of right heart failure.
73
MECHANISM OF PLEURITIC PAIN
1. Involvement of the pleural surface of the lung adjacent to a resultant pulmonary infarction;
2. Distention of the pulmonary artery;
3. Right ventricular wall stress and/or
subendocardial ischemia related to acute
pulmonary hypertension
74
Modified Well's criteria
Study from the table
75
PE score
```
>6- High
2.0-6.0- Moderate
<2.0- Low
PE likely- >4.0
PE unlikely- <= 4.0
```
76
If low probability
D-dimer
77
If moderate to high probability,
we proceed to CT
| angiogram
78
PNEUMOTHORAX
● Abnormal collection of air in the pleural space
between the lung and the chest wall
● Clinical manifestation s:
○ sudden onset of sharp, one-sided chest
79
1 Spontaneous Pneumo
Rare, Risk includes males, smoking, Marfan's; sudden onset, Mild Dyspnea
80
2 pneumo
Underlying disorder, COPD
81
Tension Pneumo
Emergency, Hemodynamic collapse due to Intrathoracic air, Shifting if trachea to the opp side of the collapsed lung.
82
GASTROINTESTINAL DISORDERS
● Most common cause of nontraumatic chest
discomfort
● Esophageal disorders may mimic angina in the
character and location of the pain.
83
Esophageal Spasm
ntense, squeezing,
retrosternal, may be relieved by nitroglycerin or
Ca-blocker (Mimics pain of angina)
84
Burning
GERD and esophageal dysmotility
85
Peptic Ulcer
60-90min, burning, Epigastri, Antacis
86
Cholecystitis
Prolonged, Aching/colicky, Epigastric, RUQ, may follow meal
87
Costochondritis
vaqriable, Aching, Sternal
88
ELECTROCARDIOGRAPHY
● Crucial in the evaluation of nontraumatic chest
discomfort.
● Pivotal for identifying patients with ongoing
ischemia as the principal reason for their
presentation, as well as secondary cardiac
complications of other disorders.
● Primary goal: identify patients with ST-segment
elevation diagnostic of MI who are candidates for
immediate interventions to restore flow in the
occluded coronary artery.
89
Despite the value of the resting ECG, its
| sensitivity for ischemia is poor
as low as 20％ in
| some studies.
90
ST SEGMENT AND T WAVE ABNORMALITIES
May occur in a variety of conditions including pulmonary embolism, ventricular hypertrophy, acute and chronic pericarditis, myocarditis,
electrolyte imbalance, metabolic disorders.
● Hyperventilation associated with panic disorder can also lead to nonspecific ST and T wave abnormalities.
91
PULMONARY EMBOLISM
● Sinus tachycardia is the most common finding
● Can also lead to rightward shift of the ECG axis manifesting as an S wave in lead I with a Q wave and T wave in lead III.
92
PERICARDITIS
● Diffuses ST segment elevation
| ● PR segment depression
93
CHEST RADIOGRAPHY
● Performed routinely when patients present with
acute chest discomfort and selectively when
individuals who are being evaluated as
outpatients have subacute or chronic pain.
● Most useful for identifying pulmonary processes,
such as pneumonia or pneumothorax.
94
Aortic dissection
widening of
| the mediastinum
95
Pulmonary embolism
Hampton’s hump or
| Westermark’s sign
96
Chronic pericarditis
pericardial calcification
97
CARDIAC BIOMARKERS
● Detects presence of circulating proteins released
from damaged myocardial
● D/t superior cardiac tissue-specificity compared
with creatine kinase MB, cardiac troponin is the
preferred biomarker for the diagnosis of MI and
repeated in 3–6 hrs.
● Includes D-dimer test to aid in exclusion of
pulmonary embolism.
● Measurement of a B-type natriuretic peptide is
useful when considered in conjunction with the
clinical history and exam for the diagnosis of
heart failure.
● Provides prognostic information among patients
with ACS and those with pulmonary embolism
98
CARDIAC TROPONIN
● Superior cardiac tissue specificity compared with creatine kinase MB
● Preferred biomarker for diagnosis of MI
● Should be measured in all patients with
suspected ACS at presentation and repeated in 3-6 hours.
● Testing after 6 hours is required only when there is uncertainty regarding the onset of pain or when stuttering symptoms have occurred.
99
ACUTE MYOCARDIAL INFARCTION
Diagnosis of MI is reserved for acute myocardial injury that is marked by a rising and/or falling pattern with at least one value exceeding the 99th
percentile reference limit and that is caused by ischemia.
100
INTEGRATIVE DECISION AIDS
● Multiple clinical algorithms
● Used in decision making during the evaluation and disposition of patients with acute non traumatic chest pain
● Used most commonly to identify patients with a low clinical probability of ACS who are candidates
either for early provocative testing for ischemia or for discharge from the ED.
101
PROVOCATIVE TESTING FOR ISCHEMIA
● Exercise electrocardiography (―Stress testing‖)
102
Early exercise testing is safe in patients without
| high-risk findings
8-12 hours of observation
and can assist in refining their prognostic
assessment.
103
low-risk patients who underwent
exercise testing in the first 48 hours after
presentation, without evidence of ischemia, had a
2％rate of cardiac events through 6 months,
whereas the rate was 15% among patients with
either clear evidence of ischemia or an equivocal
result.
104
RESTING MYOCARDIAL PERFUSION SCAN
● Ongoing chest pain is a contraindication to stress testing
● Indicated for persistent pain and non-diagnostic ECG and biomarker data
● Absence of any perfusion abnormality
substantially reduces the likelihood of coronary artery disease
● Management of patients with normal perfusion images can be expedited with earlier discharge and outpatient stress testing, if indicated.
105
ECHOCARDIOGRAPHY
● Not necessarily routine
● detection of abnormal regional wall motion
provides evidence of dysfunction in patients with
an uncertain diagnosis
106
ECHOCARDIOGRAM
Diagnostic in patients with mechanical
complications of MI or inpatients with pericardial
tamponade
107
Transthoracic echocardiography
poorly sensitive for aortic dissection, although an intimal flap may sometimes be detected in the ascending
aorta.
108
CT ANGIOGRAPHY
Coronary CT angiography is a sensitive
technique for detection of obstructive coronary
disease, particularly in the proximal third of the
major epicardial coronary arteries. CT appears to
enhance the speed to disposition of patients with
a low-intermediate probability for ACS; its major
strength being the negative predictive value of a
finding of no significant disease. In addition,
contrast-enhanced CT can detect focal areas of
myocardial injury in the acute setting as
decreased areas of enhancement
109
CT angiography can exclude
aortic
dissection, pericardial effusion, and pulmonary
embolism
110
CARDIAC MRI
● Structural and functional evaluation of the heart and the vasculature of the chest
● Modality for pharmacologic stress perfusion imaging
● Early detection of MI, defining areas of
myocardial necrosis accurately, and can
delineate patterns of myocardial disease that are often useful in discriminating ischemia from nonischemic myocardial injury.
● Cardiac structural evaluation of patients with elevated cardiac troponin levels in the absence of definite coronary artery disease.
● Highly accurate assessment for aortic dissection.
