Chest pain Flashcards
(146 cards)
1
Q
What RF can increase atherosclerosis
A
- cocaine
- HIV
2
Q
classic presentation of CP
A
- 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
3
Q
onsets of classic chest pain presentations
A
Sudden or gradual:
* Angina: 2-10 min
* Unstable angina: 10-30 min
* AMI pain: >30 min
4
Q
Two categories of ”chest pain” based on nerve fiber:
A
- 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
5
Q
atypical CP presentation can be seen in who?
A
- Pre & early menopausal women
- Racial minorities
- DM
- Elderly
- Pts w/ psychiatric disease or AMS
6
Q
If any of these sx are present, it is unlikely an AMI:
A
- pleuritic in nature
- Positional
- sharp
- reproducible with palpation/positioning
7
Q
Possible PE findings for cardiac CP
A
- 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
8
Q
perform an EKG within ___ min if concern for myocardial ischemia
A
10
9
Q
ECG findings of acute MI
tx?
A
new ST elevations ≥1 mm in two contiguous leads
rapid reperfusion interventions
10
Q
ECG findings of ____ indicate ischemia → further eval
A
New ST elevations, Q waves, LBBB, T-wave inversions or normalizations in sx pts
11
Q
CXR of classic CP presentation
A
nml MC
r/o thoracic aortic aneurysm, aortic dissection, pneumonia, pneumothorax, PE
12
Q
next imaging choice after CXR?
r/o for what dx?
A
Non-contrast CT
PNA, pneumothorax
13
Q
imaging modility for aortic aneurysm/dissection or PE
A
Chest CTA
14
Q
ECHO Emergent may be useful with what severe dx?
A
- aortic dissection, cardiac tamponade, new regurg murmur
- This will vary on the hospital and staff/providers available
15
Q
Other tests based on suspected DDx for chest pain
A
- CBC
- BMP or CMP
- PT/PTT
- ABG
- Type and Crossmatch
- Hcg in women of childbearing age
16
Q
Best serum marker for myocardial injury
A
Troponin
17
Q
AMI troponin measurements (onset, peak, elevated)
A
- Onset: 4 hours after onset of acute MI
- More reliable 6 hr after sx. - Peak: 24-48 h
- Elevated: 10 d
18
Q
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
A
CK-MB
19
Q
Red flags during initial triage for chest pain
A
- 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
20
Q
Hx for initial chest pain triage
A
- Should be FOCUSED!
- Include sx and the 7 attributes
- Focused PMH
- Assess for risk factors
- ROS - focused on DDx
21
Q
sudden, pleuritic CP, focal chest w/ dyspnea, tachypnea, tachycardia, or hypoxemia.
what ddx
A
Pulmonary Embolism
22
Q
RF for Pulmonary Embolism
A
prolonged immobilization, active cancer, recent surgery/trauma, procoagulant syndromes, exogenous estrogen, or previous thromboembolic disease.
23
Q
Criterias used for PE
A
Wells, Revised Geneva Scores, PERC
24
Q
diagnostics for PE
A
D-dimer
CT pulm angiography
25
* 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
26
RF aortic dissection
male, >50y, uncontrolled HTN, CTD, cocaine, bicuspid valve or AV replacement, pregnancy
27
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
28
* 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)
29
what is Hamman’s crunch
crepitus on cardiac auscultation
30
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.
31
esophageal rupture most often in the _____ of the esophagus, resulting in a _____
**distal ⅓** of the esophagus resulting in a **pneumomediastinum**
32
tx esophageal rupture
1. Stabilize air way
1. **NPO, IV fluids**
1. Broad spectrum IV antibiotics
1. 1st line: **ampicillin/sulbactam or pip/taz**
- BL allergy: **clindamycin + ciprofloxacin**
1. **NG or OG tube placement** - prevent further saliva and gastric content contamination
1. Consult surgery
33
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
34
sharp, severe, constant, and **retrosternal that radiates to back, neck, or jaw; worsened supine, relieved sitting forward; pericardial friction rub**
Acute Pericarditis
35
ECG shows PR depressions, diffuse ST-segment elevations, or T-wave inversions; diffused
what dx?
Acute Pericarditis
36
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
37
s/s of GI causes of CP
1. _Gastritis_: **gnawing / burning pain** in **lower chest**
1. _PUD_: **postprandial dull, boring pain** in **epigastric** region
1. _Esophageal spasm_: reflux disease; sudden onset of dull or tight substernal chest pain; **precipitated by drinking cold liquids** and can be **relieved by NTG**
38
initial management for chest pain
1. Placed in a treatment bed quickly
1. Cardiac monitoring and IV access (2 large bore)
1. EKG (within 10 minutes)
1. Measure vital signs, then resuscitate as needed, following the ABCs
1. supplemental O2 if O2 saturation at rest is **< 95%***
39
for chest pain presentation; admit if they meet this criteria:
1. Positive cardiac enzymes
1. New concerning EKG changes
1. Persistent pain
1. Concerning physical exam findings
40
Heart Scoring
0-3 = DC
4-6 = Admit to observe
7-10 = early invasive strategies
41
MC sx of ACS
1. **MC Chest pain**
- substernal or left-sided CP,
- **radiation to one or both arms**, accompanied with **N/V, diaphoresis**.
- "Pressure"
- Exertional
2. Pallor, diaphoresis, AMS, elevated JVD, peripheral edema, or rales
42
atypical sx for ACS
SOB, N, diaphoresis, back pain, abd pain, dizziness, palpitations
43
RF for CAD
older, male, FHx, smoking, HTN, hypercholesterolemia, DM, cocaine
44
presentation of unstable angina
CP (or atypical ACS sx) + obstructive CAD and has one of the following:
1. began within past 2 months
1. has increasing frequency, intensity, or duration of existing angina sx
1. existing angina begins to occur at rest
45
Dx ACS
cTn, CBC, lytes, PT/PTT, CXR
46
goals for care in ACS
1. reperfusion by reducing thrombus
1. limiting thrombus extension
1. relieving obstructive CAD
47
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.
48
If no PCI is available, what do you use
fibrinolytics IF:
1. < 6-12 hrs of sx onset
1. ECG 1 mm ST elevation in 2 contiguous leads
1. Full dose anticoag for 48 hrs
1. Avoid: arterial puncture, venipuncture, central lines in areas which are not readily compressible
49
tx for suspected ACS
1. cardiac monitoring, IV line, O2 if < 95%.
1. **ASA** 160-325 mg PO chewed; Alt: Clopidogrel
1. **NTG** PO, transdermal, or IV to treat any ongoing angina.
1. **Morphine** if pain continues despite NTG.
2. **Metoprolol** in first 24h
3. +/- antiplatelet
- Dual therapy: _clopidogrel w/ ASA_
- Antithrombin: _heparin/enoxaparin_
50
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
51
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
52
tx STEMI
immediate cath
53
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.
54
tx for Refractory cardiogenic shock
emergent angioplasty
Other: Intraaortic balloon pump or other LVADs
Admitted to critical care unit
55
tx NSTEMI or unstable angina w/ ongoing CP, ECG changes, dysrhythmias, or hemodynamic compromise
admitted in cardiac ICU
56
tx for Unstable angina but no/resolved s/s
admitted to monitored inpatient bed
57
thrombolytic options
1. **tPA**
1. **Reteplase (rPA)** - Pro: double bolus rather than continuous infusion
1. **Tenecteplase (TNK)** - alt for tPA
1. **Streptokinase (SK)**
- Can cause allergic reaction
- CI: HoTN, prior SK within 6 mo, strep within year
- Start heparin within 4 hrs of starting SK
58
complications for thrombolytics?
tx?
bleeding/intracranial hemorrhage
1. DC thrombolytics, heparin, ASA
1. Crystalloid and RBC infusion possible
1. Cryoprecipitate + FFP
1. **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)
59
what med is given the first 24 hrs of admission if significant tachycardia or HTN for ACS/MI/unstable angina?
BB PO
60
Upon completion of the primary evaluation, classify patients into one of
the following categories of the prognosis-based classification system: (4)
1. Acute myocardial infarction (AMI)
1. Probable acute ischemia - Additional TIMI & HEART
1. Possible acute ischemia - Additional TIMI & HEART
1. Definitely not ischemia
61
secondary assessment for CP pt with No ST elevation
**serial cTn** to r/o MI
- Low-risk - 2 cTn measurements 2 hrs apart; one measurement at least 6 hrs after onset of pain
- Does not r/o unstable angina
62
secondary assessments for continued suspicion for ACS w/ negative biomarkers
cardiac testing
1. exercise/pharm ECG stress test
1. Stress Test: echo, nuclear imaging, MRI
1. CTCA
1. Cath
63
MC cardiomyopathy
Dilated cardiomyopathy
idiopathic (MC), familial, secondary
64
what is Peripartum CM
dilated cardiomyopathy affecting **pregnant women** from _20 wks into postpartum period_
65
what type of cardiomyopathy condition is the primary indication for cardiac transplant?
dilated CM
66
s/s Dilated CM
1. _Acute HF from systolic pump dysfunction_
- DOE, orthopnea, paroxysmal nocturnal dyspnea
- Rales, dependent edema, hepatomegaly, **holosystolic murmur**
- CP possible
67
diagnostic findings of dilated CM
* ECG → LVH, LAE, Q/QS waves, poor R wave progression across precordium
* CXR → enlarged cardiac silhouette, biventricular enlargement, pulm vascular congestion
* **_Dx: ECHO_** → ↓ EF, ventricular enlargement, ↑ systolic & diastolic volumes
68
management for new and old dilated CM?
1. New - admit; monitored or ICU
1. Known CM → identify cause - MI, anemia, infection, afib, bradyarrhythmia, valvular insufficiency, renal dysfunction, PE, thyroid dysfunction
69
complex ventricular ectopy in dilated cardiomyopathy may be treated with ?
amiodarone
70
chronic therapy for dilated CM
1. **diuretics, digoxin** - improves sx, _no effect on survival_
1. **ACE, BB (carvedilol)** - better for survival
71
management for advanced dilated CM
LVADs while awaiting transplant
72
a common cause of dilated CM
Inflammation of myocardium - Systemic disorder or infectious agent
Pericarditis MC accompanies
Myocarditis
73
s/s Myocarditis
- **Nonspecific - Myalgias, HA, rigors, F, tachycardia**
- CP, pericardial friction rub
- **Severe - HF: DOE, Rales, Pedal edema, Cardiogenic shock**
74
w/u for myocarditis
1. **ECG** - nml; nonspecific
- AV block , prolonged QRS, ST elevation, PR depression
2. **CXR** - nml; pulm congestion (severe)
3. **Biomarkers** - elevated
75
management for myocarditis
1. **Admit, supp care = mainstay**
1. Abx with suspected bacterial myocarditis
1. Progressive HF - ICU
76
what is a LVAD
Implanted pump transferring blood from apex of LV to proximal aorta
77
PE of LVAD
1. Pump creates continuous blood flow to maintain nml MAP - **May not have nml palpable pulse**
1. BP obtained by **doppler or mechanical cuff**
1. **“Whirr” heart sound** from LVAD pump
2. ECG - discernible QRS
3. CXR - LVAD components
78
NEVER perform what intervention on an LVAD pt with hemodynamic instability?
why?
1. **CPR** → displaces LVAD
1. LVAD causing LV rupture with intractable hemorrhage
79
process of listening to the heart with LVAD pt
1. “Whirr” heard → get BP, place on monitor, IV access, nml saline bolus
1. No “whirr” → enlist the pt and family to help find cause of mechanical failure and change battery and controller; do not disconnect any equipment
80
common complications and tx of LVAD
1. Infection at abdominal wall outlet → abx
1. Anemia secondary to red cell destruction from pump/hemorrhage from anticoag → blood transfusion
1. Thromboembolic event - heparin once bleeding r/o
81
LVAD: HoTN persists or RV failure, what tx?
pressors
82
what is hypertrophic CM
**Asymmetric LVH and/or RVH** involving **interventricular septum** = ↓ compliance of LV → **impaired diastolic relaxation and diastolic filling**
83
s/s hypertrophic CM
1. More severe when older
1. **DOE MC**
1. CP, palpitations, syncope; may be aware of forceful ventricular contractions
1. **S4 HS, systolic ejection murmur** heard at **lower left sternal boarder or apex** = does not radiate to neck
- **Enhanced by valsalva or stand**
- **↓ by squatting and passive leg elevation** - ↑ LV filling
84
EKG findings of HCM
nonspecifc; LVH, LAE, deep S waves with large septal Q waves and upright T waves possible
Inverted T waves = ischemia
85
dx HCM?
echo = disproportionate septal hypertrophy
CXR nml
86
management for HCM
1. **Mainly supp**
1. Suspected hypertrophic CM → **echo**
1. Suspected hypertrophic CM + _syncope_ → **admit for cardiac monitoring and eval** - sudden cardiac death!!
1. _When definitive dx_ → **atenolol**
87
CM - Uncommon; idiopathic or secondary
Sarcoidosis, scleroderma, amyloidosis
Ventricular filling restricted → nml or diminished diastolic volume, systolic nml
Restrictive CM
88
s/s Restrictive CM
1. **Dyspnea, orthopnea, pedal edema** W/O assoc CM or systolic dysfunction
1. _CP UNCOMMON_
1. PE - consistent with degree of disease
- **S3/S4**
- Cardiac gallop
- Rales
- **JVD, inspiratory JVD (kussmaul sign)**
- Hepatomegaly
- Pedal edema
- Ascites
89
diagnostic findings in restrictive CM
* ECG - nonspecific; conduction disturbances, low voltage (sarcoidosis/amyloidosis)
* CXR - HF w/o cardiomegaly
90
management for restrictive CM
1. Admit
1. **Diuretics & ACEI** → sx control
1. Tx underlying
- _Sarcoidosis_ → **corticosteroid**
- _Hemochromatosis_ → **chelation**
91
what is Acute Pericarditis including causes
* Inflammation of layers covering heart
* **Idiopathic or infection** (virus, bacterial, fungus)
* Causes: malignancy, drugs, radiation, CTD, uremia, myxedema, **postmyocardial infarction (Dressler’s syndrome)**
92
MC - sharp/stabbing precordial or retrosternal CP - radiating to back, neck, shoulder, or arm
Worsens lying supine, movement, swallowing, inspiration
Alleviated by sitting up and leaning forward
Assoc sx - infection, low-grade F, dyspnea, dysphagia
PE - nml; friction rub at lower left sternal border or apex
what dx
acute pericarditis
93
ECG acute pericarditis
Stage 1 - diffused ST elevation - I, V5, V6; PR depression II, aVF, V4-6
Stage 2 - ST normalized; T-wave amplitudes ↓
Stage 3 - T-wave inversion - I, V5, V6
Stage 4 - Normalized ECG
94
if sequential EKGs are not avail, what EKG findings are suggestive of pericarditis?
ST-segment/T-wave amplitude ratio > 0.25 in leads I, V5, or V6
95
tx for Stable, idiopathic/presumed viral pericarditis
outpatient, ibuprofen
96
ED mgmt when to admit pericarditis pts?
* **Colchicine** - beneficial adjuvant, can prevent recurrence
* Pericarditis + _myocarditis/enlarged cardiac silhouette/effusion via echo/uremic pericarditis/ hemodynamic compromise_ → **admit**
97
Fluid **accumulation in pericardial space** → exceeds pressure of RV → tamponade = restricted filling and ↓ CO
Nontraumatic cardiac tamponade
98
causes of Nontraumatic cardiac tamponade
1. uremia
1. malignant effusion/Metastatic Malignancy
1. hemorrhage d/t anticoag
1. bacterial or tubercular infection
1. chronic pericarditis
1. lupus, radiation, myxedema, idiopathic
1. Penetrating or blunt chest wall trauma
99
Development of diastolic dysfunction results in relation to:
1. rate of fluid accumulation
1. pericardial compliance
1. intravascular volume (hypovolemia lowers ventricular filling pressure)
100
s/s cardiac tamponade
1. Mild to severe shock
1. **MCC - dyspnea**
1. Tachycardia, **HoTN/low SBP, narrow pulse pressure**
1. **Pulsus paradoxus - drop in SBP >10 during normal inspiration**
1. Neck vein distention, distant HS, RUQ pain (hepatic congestion)
1. NO RALES
1. **Beck’s Triad of Cardiac Tamponade**
- Hypotension
- JVD
- muffled heart sounds
101
ECG of cardiac tampanode
* low-voltage/small QRS, ST elevations w/ PR depression as in pericarditis
* Electrical alternans
102
diagnostic for cardiac tampanode
**_TTE_** - Large pericardial **effusion with RA/RV diastolic collapse**
TTE - most sensitive and specific; US can be used too
103
cardiac tampanode can lead to HoTN and cardiac arrest with ____
pulseless electrical activity (PEA)
104
mgmt cardiac tampanode
1. Peripheral IV, O2, continuous cardiac monitoring
1. BP monitoring q5-15 min
1. IV saline/**Large bore IV fluids** - helps with right heart filling, temp improves hemodynamics
1. **Pericardiocentesis** when hemodynamically stable
- Emergency pericardiocentesis
if signs of decompensation, performed at bedside with US and/or EKG guidance
- Urgent consult to cardiology and cardiothoracic surgery for pericardiocentesis
105
what is constrictive pericarditis
* Pericardial injury/inflammation → abnml diastolic filling → constrictive pericarditis
* Causes: fungal, TB pericarditis, uremic pericarditis, postcardiac trauma, post surgical changes after pericardiotomy
106
presentation constrictive pericarditis
1. Gradual development of sx similar to **HF and restrictive CM**
- DOE, pedal edema, hepatomegaly, ascites
- **Kussmaul’s sign frequent**
107
w/u and findings for constrictive pericarditis
1. ECG: Nonspecific; small QRS, inverted T waves
1. CXR - nml; enlarged cardiac silhouette
1. 2D Echo - not helpful!!
1. **Dx: CT/MRI/Doppler echo**
108
mgmt constrictive pericarditis
1. Eval ventricular function
1. Surgical pericardiectomy if significant construction and impaired ventricular filling
109
AAA definition
1. **≥3.0 cm in diameter**
1. Symptomatic aneurysms and ≥5.0 cm require prompt operative repair
1. Emergent!!
110
classic presentation of aortic rupture
* Older male, smoker, atherosclerosis; Sudden severe back or abd pain; HoTN; Pulsatile abdominal mass
* Syncope, pain localized to flank, groin, hip or abdomen possible
* Severe and abrupt ripping/tearing pain = rupture
* Femoral pulsations nml
* Retroperitoneal hemorrhage rarely
111
Aortoenteric fistula presentation
* **GI bleeding** - small or life-threatening
* H/o aortic grating at higher risk
* **Duodenum MC site for fistula**
* Hematemesis, melena, hematochezia
* High output cardiac failure with ↓ arterial blood flow distal to fistula
112
presentation of Rupture into retroperitoneum
* Fibrosis → chronic contained rupture
* Appear nml, may have pain for long time before dx is made
113
MC incorrect initial dx of aortic rupture/AAA
**Renal colic**
Back pain, intraabdominal process, testicular torsion , GI bleeding
114
additional w/u when dx is unclear with AAA
1. Bedside abd US - >90% sensitivity
- Aortic rupture/retroperitoneal bleed not reliably identified
1. CT - can delineate where aneurysm and any associated rupture
115
possible XR finding with AAA
calcified, bulging aortic contour (only in some)
116
general mgmt for AAA
* Consult vascular surgeon if rupturing AAA or aortoenteric fistula
* **Fluids** (for HoTN)
* **Target SBP: 90mmHg**
* **Tranfuse PRBC** if needed
* **Pain control** while avoiding HoTN
117
tx small asx AAA (3-5 cm)
* Incidental finding
* Refer to vascular surgeon
118
tx for Large AAA (>5cm)
Higher risk for spontaneous rupture; close f/u
119
dx & mgmt/tx for Nonaortic large-artery aneurysms
**Dx: US/CT**
1. _Popliteal/femoral_ - thrombolysis, ligation, arterial bypass, endovascular repair
1. _Hepatic_ - surgical ligation, embolization
1. _subclavian/femoral pseudoaneurysm/ renal/splenic_ - surgical repair
- _renal/splenic_ - +ectomy
120
for Aortic Dissection, the blood dissects between ___ and ___ layers of aorta
intimal
adventitial
121
RF aortic dissection
1. **MC male, >50y, h/o HTN**
1. Chronic cocaine use
1. h/o cardiac surgery
1. Younger pts - CTD, congenital heart disease, pregnancy - _Marfan’s syndrome_
122
presentation aortic dissection
Acute CP
- Most severe at onset
- Radiates to back
- Sharp, ripping, tearing pain
- Syncope possible
- Location dependent on area of aorta involved:
--- Anterior CP - ascending aorta
--- abd/back pain - descending aorta
--- Diastolic murmur of aortic insufficiency possible
--- HTN and tachycardia common; HoTN can be present
- ↓ pulsation in radial, femoral, or carotid arteries
- Neurologic sequelae
123
what is Stanford Classification ?
aortic dissection
Type A - Ascending Aorta
Type B - descending Aorta
124
what is DeBakery Classification
* Type I - ascending & descending
* Type II - ascending only
* Type III - descending only
125
presentation of progressed dissection
* AV insufficiency
* _coronary artery occlusion_ - **myocardial infarction**
* _carotid involvement_ - **stroke sx**
* _occlusion of vertebral blood supply_ - **paraplegia**
* _cardiac tamponade_ - **shock and JVD**
* _compression of recurrent laryngeal nerve_ - **hoarseness of the voice**
* _compression of superior cervical sympathetic ganglion_ - **Horner’s syndrome.**
126
w/u and findings with dissection? What is the diagnostic w/u?
1. D-Dimer
1. CXR
- _MC - Abml aortic contour, widening mediastinum_
- Deviated trachea, mainstem bronchi, esophagus, apical capping, pleural effusion, displacement of aortic intimal calcifications
1. **Dx: CT w/ contrast; TEE**
127
tx aortic dissection
1. Consult vascular or thoracic surgeon
1. **Fluids**
1. **Esmolol/labetalol**
- _Goal HR: 60-70_
- _Goal SBP: 100-120_
1. _SBP >120_ → **nitroprusside/nicardipine**
128
HTN emergency definition
Defined as a **SBP >180 and/or DBP >120**
BP should be assessed in both arms multiple times
129
Two types of hypertensive crisis
1. _HTN urgency_ - no evidence of end-organ damage
1. _HTN emergency_ - evidence of end-organ damage
- **brain, heart, aorta, kidneys, eyes**
130
s/s of HTN emergency
1. Brain: HTN encephalopathy, SAH, ICH, Ischemic CVA
1. Heart: Acute pulmonary edema, MI, ACS
1. Aorta: Aortic dissection
1. Kidney: Acute renal failure
1. Eyes: Hypertensive retinopathy
1. Multiorgan: Preeclampsia, Eclampsia, Acute perioperative HTN, Sympathetic crisis
131
for HTN emergencies how do you eval them?
Look for signs of end-organ damage
H&P
1. Mental status changes, neurologic dysfunction, seizure, acute severe HA
1. Visual changes, retinopathy, papilledema
1. Sudden onset chest pain
1. Dyspnea
1. Peripheral edema
1. Oliguria
132
labs that indicate end-organ damage
1. BMP: acute elevation of serum creatinine
1. UA: proteinuria, RBC, or red cell casts
133
imaging needed for HTN emergencies
1. **CXR** - pulmonary edema or thoracic aortic dissection
1. **ECG** - cardiac ischemia
1. **CT head w/o contrast** - neurologic changes/CVA
- Follow up with **CTA head & neck** if noncontrast CT is negative
1. **CTA chest** - chest pain/aortic dissection
134
tx HTN urgency
1. BP control within **24–48 hours**
1. _No hx of HTN_: **HCTZ**
1. _Hx of HTN_: **reinstitution** or **intensification of oral antiHTN**
1. **DC home with rapid follow-up** with PCP
135
tx HTN emergency
* Rapid, controlled reduction in BP w/ IV antiHTN
2. Reduce SBP by no more than 25% in the first hour
3. If stable: reduce to 160/100 over next 2-6 hrs
4. If stability remains reduce to normal over the following 24 to 48 hour
* Admit to a critical care floor (CCU, ICU)
136
3 conditions that are the exception in reducing SBP by no more than 25% in the first hour during HTN emergency
Aortic dissection, acute ischemic strokes, intracerebral hemorrhage
137
HTN emergency: Rapid reduction of BP can lead to ?
watershed cerebral infarction
138
which agent is preferred for SAH, ischemic stroke
**Nicardipine** (Cardene) - CCB
139
Nicardipene may precipitate myocardial ischemia, what other agents are alternatives
1. **Labetalol** (Trandate)
1. **Enalaprilat** (Vasotec)
140
which antiHTN agent is used in most patients, aortic dissection, stroke
Labetalol (Trandate)
141
which antiHTN agent is preferred for aortic dissections
Esmolol (Brevibloc)
142
which antiHTN agent is preferred for renal insufficiency or failure; May protect kidney function.
Fenoldopam (Corlopam)
143
which antiHTN agent is preferred for CHF, stroke
Enalaprilat (Vasotec)
144
which antiHTN agent is preferred in pregnancy
hydralazine (apresoline)
**Avoid in CAD, dissection**. Rarely used except in **pregnancy**.
145
which 2 antiHTN agents should be avoided in acute LV systolic dysfunction, asthma.
Labetalol (Trandate)
Esmolol (Brevibloc)
146
which antiHTN agent is no longer the first-line agent d/t wide variety of SE?
Nitroprusside (Nitropress)
