Chest Pain DSAs Flashcards
(70 cards)
1
Q
If a patient presents with chest pain, what are 2 questions you should be sure to ask?
A
- Frequency
- Does it wake you up at night
2
Q
Risk factors for CVD
Age:
___ is a major risk factor
Other: HTN, hyperlipidemia, smoking, sedentary/obestity, family Hx, stress, sleep disturbances
A
Men over 55 YO; Women over 65 YO
DM
3
Q
What are the 7 SERIOUS potenially lethal causes of Chest Pain?
A
- 1. M. ischemia
- 2. MI (acute-AMI); STEMI/NSTEMI
- 3. Aortic dissection
- 4. PE
- 5. Tension pneumothorax
- 6. Esophageal rupture
- 7. Pericarditis (effusion/tamponde)
4
Q
PE findings associated with CV disease?
S4 gallop is heard _____
S3 gallop is heard _____
A
- Xanthema in eyes and elbows
- Nicotine stains on fingers, hair, odor
- Bruits (turbulent sounds)
- S4 gallop: angina
- S3 gallop: heart attack
- Mitral regurg, often due to dysfx of papillary muscle
- Diaphoresis
5
Q
What can mimic angina in the absence of CAD?
A
1. Aortic insuff/ aortic stenosis/ Pulmonary HTN
2. Hypertrophic cardiomyopathy
3. Coronary spasm
4. HF
6
Q
Differential dx of a STEMI?
A
- Pericarditis, myocarditis
- Stress induced Takotsubo cardiomyopathy (mimics ACS, LV apical balloning)
- Early ventricular repolarization in healthy patients, esp in AA
7
Q
What can increase troponin level?
A
- Damage to myocardium
- Contusion, surgery, shock
- cardiomyopathies, HF
- Aortic dissection, AI, severe AS
- Tachycardia
- Pulmon: PE, pulm HTN, RF
- Renal: renal failure, shock
- Neurogenic: stroke or intracranial hemorrhage.
8
Q
What will CBC show with STEMI?
A
mildly elevated WBC
- check troponin and CK-MB
9
Q
CMP Panel shows what?
A
electrolytes, Mg, Ca, BUN, LFT
10
Q
When are BNP levels increased?
A
- HF
- Stress to wall of ventricle d/t too much fluid
11
Q
CRP may be ______ in STEMI?
A
increased
12
Q
What is the initial stress test should we do if STEMI?
A
- Treadmill excercise
Then, stress echo to look at motion of wall, valve function and monitor cardiac rhythm.
13
Q
When should pharmacologic stress testing be done w CP?
What are they?
A
When patient cannot excercise
- Vasodilator nuclear perfusion (via adenosine or regadenoson)
- Dobutamine nulcear perufsion (if cannot tolerate vasodilator or excercise)
- Dobutamin echo
14
Q
What imaging should be done when a patient has chest pain?
A
- CXR
- Echo
- Cardiac MRI to look at thickness of wall and size of chambers.
15
Q
Supply angina is caused by what?
A
Decrease in O2 supply to the heart due stenosis, vasoconstriction, causing platelets to release 5HT and TXA2 => platelet aggregation
16
Q
Demand angina is caused by what?
A
<3 needs more O2 due increased workload => ischemia
- stress, excerise, fever, thyrotoxicosis, LVH due to AS, anemia
17
Q
What are symptoms of stable angina?
Pattern of pain?
A
- Chest pain on exertion, emotion, stress that lasts 5-15 minutes and is relieved by rest of nitro.
- Does not change in freq, duration or intensite
18
Q
What does a patient with stable angina show on ECG?
A
- 50% have NL ECG
- -ST depression/ST elevation
19
Q
What is a unstable angina?
A
- ACS (acute coronary syndrome) that causes CP due to rupture of a atherosclerptic plaque => platelet aggregation and thrombus formation that partially occludes the artery.
- Increase frequency, severity, lasts longer than 15-20 minutes that occurs at rest/less effort.
20
Q
NSTEMI myocardial infarction (NSTEMI) is distinguished from unstable angina by…
A
NSTEMI will have:
- High levels of cardiac enzymes (troponin/CKMB)
- Biomarkers of myocyte necrosis
21
Q
What does NSTEMI look like on ECG?
A
- ST depression
- T wave inversion
22
Q
How do we treat stable angina?
A
- 1. Low sat/trans fat diet, low Na+ diet, lose weight
- Nitroglycerin as needed for CP; 1 sublingual tab/5min; do not take 3 in a row.
- Long acting nitrates, B-blocker, CCB for coronary spasm, aspin, ACE-I
23
Q
How do we treat ACS (unstable angina/NSTEMI)?
A
- Nitroglycerin, B-blocker, ASA, statin
- ACE-I
- Platlet ANT/aNTi-coag
24
Q
What is a STEMI?
A
- ST-elevated MI: Thrombus formed by erosion, fissure or rupture of plaque that completely interupts flow to heart (transmural)
- D/t; atherosclerosis**, coronary spasm, vasculitis, dissection
25
What is the ECG criteria for a **STEMI**?
* **ST elevation in 2 continguous limb leads**
* or
* **2 mm ST elevations in 2 continous precordial leads or new LBBB**
26
Describe the pain in a STEMI?
* More severe than angina and cannot be relieved by NTG or rest
* substernal =\> neck/jaw =\> left arm
* N/V, SOB, sweating
27
Are all STEMIs painful?
**20% are painless**, esp in elderly female with DB
28
How do we treat **STEMI**?
* 1. **Hospital** + **cardiac catheterization**
* 2. **PCI** (percutaneous coronary intervention) or **fibrinolytic therapy** (clot buster)
29
**Valvular heart disease** most commonly are due to what?
**_Senile calcification/degeneration._**
## Footnote
Other: myxocmatous degernation (MVP) or congenital (BAV)
30
**Murmurs** are a result of what?
* 1. **Tubulence** across valve
* 2. **Increase blood flow** (anemia/pregnancy)
31
**Stenosis** creates ____ overload, causing what?
* **Pressure** overload
* **Hypertrophy** and **HF**
32
Regurg creates ____ overload, causing what?
**VOLUME**
**Dilates heart**
33
List the 5 valvular causes of **systolic murmurs**
**MR P.V. TRAPSS**
* **M**itral **r**egurg/**p**rolopase
* **V**SD/ASD
* **T**riscupid **r**egurg
* **A**ortic stenosis
* **P**ulmononis **s**tenosis
last s = stenosis
34
List the 4 valvular causes of **DIASTOLIC murmurs**
**_MSTS PAID "mistess paid"_**
1. Mitral stenosis
2. Tricuspid stenosis
3. Pulmonary insuf/regurg
4. Aortic insuf/regurg
Diastolic
35
**_Murmur grade scale (1-6)_**
1. Barely audible
2. Soft/faint
3. Louder, easily heard
4. **Very loud + palpable thrill (vibration)**
5. Heard with stethoscope barely touch chest + thrill
6. Can hear w/o steoth or close to chest + thrill
36
pt comes in and murmur is **very loud** with **palpable thrill.**
what grade
**4**
37
What are the 2 etiologies of **chronic** **mitral regurgitation (MR)** and which is most common?
1. **Mitral valve prolapse** = MOST common-
2. Myxomatous/ degeneration or mitral annular calcification (MAC)
38
What are 4 causes of **acute** **mitral valve regurgitation?**
Which is 2nd most common cause of MRregurg?
1. - Rupture of chordae tendineae
2. - Rupture of papillary muscle
3. - Ischemic papillary muscle dysf. due to CAD/MI
1. **2nd most common cause**
4. - Infective endocarditis(IE); valve perforation
39
**Systolic murmur** (blowing, holocystolic) that is best heard at **apex** =\> radiates to **L axilla**
**_Mitral regurg_**
40
What is **_MVP_**?
**1 or both leaflets prolapse into atrium** d/t **myxedematous degeneration**
41
Which sex is most often affected by **mitral valve prolapse (MVP)** and what are congenital defects which increase risk?
- **Women** 7:1
- Assoc. with **Marfans/skeletal changes**
42
What are the range of sx's/signs associated with **MVP**?
* **Asymptomatic** to [_arrhythmias_ (SVT, PVC's, VT), _chest pain_ and/or _syncope_]
43
F pt presents to office with hx of palpitations, dizziness, scared of habing a heart attack.
what kind of murmur is thought to be there
**MVP**
44
What is the characteristics of the murmur heard with **MVP**?
**Systolic murmur** heard **best** at the **apex** that may have a **systolic click**
will incrrease with **valsalva** and **standing**
45
Systolic murmur heard best at the apex that may have a systolic click
will incrrease with valsalva and standing
MVP
46
If patient with **MVP** is in hyper-adrenergic state (anxious, palpitations), consider using what drug class?
**Beta-blocker**
47
What are 3 causes of **Aortic Stenosis** and which is most common?
**- Most common = Degeneration calcification of valve (---\> persons \>65 yo**
- Congenital or acquired bicuspid aortic valve (BAV)
- Rheumatic/post-inflammatory scarring (radiation)
48
Which decade does **aortic stenosis** typically manifest in and what are the 4 cardinal signs/sx's?
1. **- 6th decade**
2. **- Exertional dyspnea**
3. **- Angina**
4. **- Syncope**
49
The obstruction in **aortic stenosis** leads to what type of overload (pressure/volume) and what are the downstream effects?
**PRESSURE overload** --\> **LVH** --\> **↑** **pressure**= _diastolic dysf_ + _systolic HF_
50
What are the common PE findings of aortic stenosis (i.e., pulse pressure, SV and systolic pressure)?
- **NARROW** pulse pressure
- **Decreased** SV and systolic pressure
- **Delayed pulses -**-\> **Parvis** (weak w/ ↓ amplitude) or **Tardus** (late/delayed)
51
What are the characteristis of the murmur heard in **aortic stenosis** (heard best where, radiates)?
Affect on S2 sound?
* Systolic murmur (**crescendo-decrescendo**) that is **harsh at 2nd ICS at RSB** =\> radiates to sternal notch and carotics
* Decreased S2
52
What will we see on ECG with **aortic stenosis?**
**LVH** and **strain pattern** (down-sloping of ST segment - Twave)
53
**BAV** is associated with what diseases?
**Marfans**
**Turners**
54
where is **pulmonic stenosis** heart at?
**Sytolic murmur** (**crescendo-decrescendo**) heart best at the **2-3 ICS at** the **LSB** =\> radiates to **left shoulder/clavicle.**
55
**Pulmonic stenosis** may be assx with what?
**Tetralogy of fallot: PS**, **VSD**, **RVH** and **overriding aorta**
56
What dose a **VSD murmur** sound like?
**Holosytolic murmur** heard best at the **lower left sternal border** with **thrill**.
L-\> R shunt Increases with handgrip
57
What dose a **ASD murmur** sound like?
* **Systolic murmur** at the **upper LSB** with **fixed splitting of S2**
* **L =\> R shunt**
58
* **Mitral/ tricuspid stenosis**
* **Aortic/pulmonic regurg**
The narrowing of the mitral orifice seen in **MS**, leads to an increased pressure gradient where and what other changes?
- ↑ **left AV** pressure gradient
- **LA** enlargment --\> **afib**, **pulmonary vascular changes**, **RVH**
59
Most common presenting sx's of someone with **mitral stenosis (MS)?**
- **Fatigue** d/t. decreased CO
- **Dyspnea on exertion**, **cough**, **orthopnea**, PND, pulmonary edema, hemoptysis
60
What is **Ortner syndrome** associated with **MS**?
**Hoarsness** due to compression of _left recurrent laryngeal n_. as _LA ↑_ in size
61
Describe the murmur associated with **MS** (i.e., phase of cardiac cycle, best heard where/position and with what part of stethoscope)?
- **DIASTOLIC**, **low pitch**, **decrescendo**, **rumbling** murmur
- Best heard at **APEX** w/ pt in left lateral decubitus position
- Use **BELL**
62
What are the ausculatory findings of S1 and S2 in pt with **MS**?
**↑ loud S1** + **↑ S2** (P2 if PHT is present)
- Opening snap after **S2** (if leaflet is mobile)
63
Common **EKG** finding of someone presenting with sx's of severe **MS**?
**Atrial fibrillation**
64
If person with **mitral stenosis** is in sinus rhythm, they will have \_\_\_\_\_
**Left atrial enlargement**
* \*'M' shaped 'p' wave = P mitrale
65
What type of murmur is associated with **Tricuspid Stenosis** and where is it best heard?
What causes an increase and decrease in the murmur?
- DIASTOLIC, LOW pitch, decrescendo murmur at **LSB**
* - Increase w/ inspiration (Carvallo's sign)
* - Decrease w/ expiration and valsalva
66
Which wave in **JVP** is **Tricuspid Stenosis** vs. **Regurgitation** associated with?
- **TS** = prominent "A" wave in JVP
- **TR** = V wave in JVP
67
What will we see on ECG with **Tricuspid stenosis?**
**Right atrial enlargement**
68
Most causes of **pulmonic regurgitation (PR or PI)** are due to what?
**Pulmonary HTN**
69
What is the characteristic murmur heard with **Pulmonic Regurgitation** and heard best where?
**DIASTOLIC**, **decrescendo** blowing murmur at **2nd ICS LSB** = **Graham Steell**
70
There will be an **increased P2** if **pulmonic regurgitation** is due to what?
**Pulmonary HTN**
