Week 5 Chest pain Flashcards
(101 cards)
1
Q
What are the most common causes of chest pain in adolescents? what sx’s are those?
A
- 35% of chest pain is costochondritis (musculoskeletal)
- Insidious onset
- Persists for long period of time
- Positional component
- Began after repetitive use of an upper extremity
- 19% GI souce
- 16% idiopathic
2
Q
Most common cause of sudden death in athlete
A
- Hypertrophy cardiomyopathies (25% of sport related deaths)
- # 2 is commotion cordis (20%) sudden blunt impact to chest causes sudden death, in absence of cardiac damage
3
Q
what questions are important to ask in history for chest pain?
A
- Any history of sudden death in an immediate family member?
- Unexplained or exertional syncope (not after but during sports?
4
Q
most common cause of myocarditis is
A
viral myocarditis
- enterovirus, esp coxackie B virus
- adenovirus surfaced to top of list of 25% cases
- influenza and subtypes (H1N1)
- in adolescent: parvovirus B19
5
Q
when does exposure to the virus do you develop symptoms of chest pain?
A
can begin < 2 weeks after exposure
6
Q
Lab findings for myocarditis
A
- elevated troponin I levels
- completely normal coronary artery angiogram
- ECG - low QRS with ST changes
- cardiac MRI - delayed gadolinium sparing the sub endocardium
- to diagnose: endomyocardial biopsy
7
Q
if have viral myocarditis, the patient play sports?
A
No, refer to cardiologist for further management
sudden death with continued strenuous aerobic exercise in myocarditis (exercise allows virus to replicate = worsens disease = ventricular ectopy)
cardiologist will follow lifelong
if treadmill stress test and ECG are normal (wks-months)
8
Q
acute coronary syndrome (ACS) sx’s
A
GET MORE HISTORY! then send to cardiac care facility for management
- since chest pain affects every organ, want MORE history and not imaging
- Worsening in the frequency, intensity, duration, and timing (ie, nocturnal pain, rest pain) of prior anginal or anginal equivalent symptoms
- New-onset shortness of breath, nausea, sweating, extreme fatigue in a patient with a known history of CVD
- Onset of typical anginal symptoms in a patient without a history of cardiovascular disease
- New findings on physical exam of murmur (or worsening of a previously noted murmur), hypotension, diaphoresis, rales or pulmonary edema
9
Q
want to rule out psychiatric concerns bc
A
Domestic violence is one such cause of chest pain similar to myocardial infarction (MI)
10
Q
ECG changes for acute coronary syndrome
A
- ST elevation (STEMI >1mm) / depression
- pathologic Q waves
- T waves
11
Q
after completing a thorough hx/ E for chest pain…
A
Evaluate need for emergent care: if think ACS, chew an aspirin & go to ED.
ED also if seriously ill, such as pneumothorax, pulmonary embolism, pneumonia, aortic dissection, etc.
12
Q
acute pericarditis diagnosis
A
triad
- pleuritic chest pain (stab/burn pain when breathing)
- pericardial friction rub (heard leaning forward at end expiration)
- diffuse ST wave elevation
13
Q
what clinical features increase likelihood of it being an MI in patients?
A
- acute chest pain radiates to both arms
- 3rd heart sound
- hypotension
14
Q
pain that worsens with inhalation
A
pleuritic chest pain
15
Q
diagnostics for heart failure
A
- Echo
- chest xray
- ECG (structural heart disease, conduction disease)
- if normal = NOT HF
- hematocrit - anemia
- thyroid function - exclude thyroid dz
- fasting lipid panel and fasting glucose (and A1c) - screen for hyperlipidemia, metabolic syndrome, DM
- UA, BMP
- brain natriuretic peptide (BNP) - if normal = HF unlikely
16
Q
standard diagnostic for coronary artery disease
A
coronary angiography
for any obstructive lesion producing sx’s or those at risk of ACS
17
Q
when is a coronary angiography indicated
A
new systolic heart failure and angina
pt w/o angina with no previous evaluation of coronary anatomy d/t high prevalence of CAD in older adults
can exclude coronary anomalies in younger pts
18
Q
3 most important factors that determine Oxygen demand is determined are:
A
- Heart rate
- systemic BP (peripheral vascular resistance)
- Left ventricular wall tension (anything that increases heart workload)
19
Q
stable angina symptoms
A
- chest pain/discomfort from exertion, stress, large meals, cold weather
-
relieved in 1-3 mins by rest or by 1 nitroglycerin
-
< 5 mins
- if >20 mins pain = ACS
-
< 5 mins
- NOT localized pain
- Levine sign - make fist over sternal area
- substernal tightness / pressure
- more predictable
20
Q
differentials to run out for chest pain
A
- r/o non-emergent causes
- GI
- Pulmonary
- Valvular inflammatory
- Integ
- Psychological disturbances
- Issues at home
- Domestic violence
- r/o life-threatening events
- Aortic dissection
- MI
- PE
- Spontaneous pneumothorax
21
Q
unstable anginal sx’s
A
- At rest or minimal exertion chest pain, nausea, light headed, SOB, epigastric pain, diaphoretic skin
- not localized, not stabbing
- Persistent pain
- not relieved with rest or nitroglycerin
- > 10 mins
22
Q
atypical symptoms of angina and more common in who?
A
- dyspnea, indigestion, nausea, numbness in the upper extremities, jaw pain, pleuritic pain, and fatigue (rather than actual chest pressure)
- more common in diabetics, women, elderly
23
Q
If chest pain all the way to the back/ripping/tearing
A
- consistent aortic dissection
24
Q
Gold standard/first line to diagnose unstable angina:
A
on ECG - looking for downsloping or horizontal ST depression
* Stress test/exercise tolerance test within 72 hrs of angina if EKG inconclusive
* want to reproduce the stress in the heart /dyspnea on exertion under controlled situations WHEN THEY ARE NOT HAVING CHEST PAINS
* less effective in women bc women have non obstructive or single vessel disease
*
25
Contraindications to stress test
* DO NOT DO IF ACTIVE MI sx’s, EKG changes, Cardiac in nature
* active chest discomfort
* Mobility issues
* Amputees
* Schedule with hip replacement
* Dementia
only put asymptomatic patients
26
secondary prevention for coronary artery disease/vascular disease checklist:
* complete smoking cessation
* BP \< 140/90, \< 130/80 if HF or renal insuff
* eval before statin, fasting lipid panel, ALT/CK
* if \< 75: high intensity Atrovastatin 80mg/rosuvastatin 40mg
* if \> 75: moderate statin
* reduce sat fat \< 7%
* triglycerides \< 200
* 30 min exercise x7 days
* BMI 18.5-24.9
* hemoglobin A1c \< 7%
* aspirin 81mg QD (clopidgrel or warfarin if contraindicated)
* BB
* metformin
* ACE inhibitor (if have CKD or diabetes)
* influenza vaccine
27
Duke treadmill scores
* stress test point system to predict 5-year mortality using Bruce protocol
* ST-segment deviation (depression or elevation), and the presence and severity of angina during the exercise
* **score = exercise duration (minutes) - 5\*(ST deviation/mm) - 4\*(angina index)**
* low risk
* score _\>_ 5 = 5 year survival of 97%
* intermediate risk
* score between 4 and -10 = 90%
* high risk
* score _\<_ -11 = 65%
28
labs to check for stable angina
* Lipid profile
* Hemoglobin A1C
* CBC
* Anemia (limited myocardial oxygen supply)
* Hemoglbin \< 7, can have ST segment/depression
* Polycythemia
* Thrombocytopenia
* Elevated platelets
* Anything that increases viscosity of blood = impedes flow
* Serum creatinine
* B-type natriuretic peptide (BNP) (evidence of HF)
29
coronary artery disease management
* **BB for ALL pt's with MI, ACS,** or **Left ventricular dysfunction history**
* **or CCB**
* **no BB if COPD**
* **can use Ranolazine (Ranexa) instead if bradycardia & can't do BB/CCB**
* **ACE inhibitors for ALL pts with ejection fraction \< 40, HTN, DM, or CKD**
* nitrate PRN
* aspirin, clopidogrel or warfarin
* statin
* flu shot
* if meds fail: coronary angiography (PCA)
* f/u q 4-6 months 1st year, then q 4-12 months
30
On ECG,
leads II, III, aVF are what views of the heart?
inferior wall ischemia/infarc
31
On ECG,
leads I, aVL, V5, V6 shows
lateral wall ischemia infarc
32
On ECG,
leads V3, V4 shows
Anterior wall ischemia/infarc - left anterior descending artery (LAD) blockage
33
On ECG,
leads V1, V2 shows
septal wall ischemia/infarc of heart
34
evolution of MI on ECG
* minutes: ST elevation
* hours: R ave, Q wave
* 1-2 days: T wave inversion, Q wave deeper
* days: ST normalizes, T wave inverted
* weeks: ST & T normal, Q wave persists
35
a U wave is benign if…
* benign if \< 5mm
* small deflection after T wave
* can be acute MI, cardiomyopathy, hyperthyroidism, e- imbalance
36
if have 2 continuous ST segment elevation..
get to PCI capable center within 90 minutes for reperfusion
if can't, give fibrinolytic therapy within 30 minutes
37
acute STEMI management
* Reperfusion therapy or fibrinolytic therapy
* Dual antiplatelet therapy
* Anticoagulation
* Aspirin, clopidogrel
* Short term anticoag (heparin) for 2-8 days
38
Non ST-segment Elevation-ASC management
* Detailed hx, PE
* 12 lead ECG within 10 minutes of arrival
* troponin I or T now and 3-6 hrs after sx onset
* chew aspirin 162-325 mg asap
* Oxygen if needed
* daily BB
* sublingual NTG
* heparin
39
what medications worsen heart failure? (heart is unable to meet the metabolic demands of the body)
* NSAIDs/Naproxen
* CCB - depresses myocardial contractility
40
angina treatment
* smoking cessation
* BP \< 130/80 (CCB/ACE)
* statins
* PA 30 min/day 5-7x/wk
* BMI 18.5-24.9
* diabetes: Hgb A1C \< 7%
* metformin for all diabetics with CAD
* also semaglutide, empaglifozin decrease CVD deaths in DM
41
if unstable angina, #1 thing to do next?
EKG w/in 10 mins! Leads will tell location
42
what is Thrombolysis in myocardial infarction (TIMI) score?
* risk score for unstable angina/NSTEMI
* 1 pt for:
* \> 65
* _\>_3 CAD risk factors (fam hx, HTN, HLD, Dm, current smoker)
* ASA in last 7 days
* elev cardiac markers (CK-MB or troponin)
* ST deviation \> .5 mm, prior CAD \> 50%
* if score 5 (high): go to PCI center hospital within 90 mins
* if score 3-4 (intermediate): give ASA/nitrate, f/u in 72 hrs
43
ACS/MI workup/labs
* EKG w/in 10 mins
* draw troponin (peaks at 3-4 hrs) 3x, at presentation, 3 hrs, at 6 hrs
* elevated for a week
* Chest xray (r/o pneumonia, pneumothorax)
* CBC (anemia)
* BMP, fasting glucose, lipids, thyroid, mg
* consider CRP, BNP
* echo for wall motion
44
ACS/MI Treatment
* aspirin 325 chewable table asap
* NTG tab (unless had phosphodiesterase inhibitor 48 hrs ago)
* statin w/in 24 hrs of event
* BB w/in 24 hrs unless CI
* consider heparin bolus
* ALS transfer to hospital
45
unstable angina vs NSTEMI
* unstable angina: persistent ST segment **_depression_** \> 1 mm for \> 48 hrs
* no Q waves, no R waves
46
STEMI workup
1. EKG (shows persistent ST segment elevation with no LV hypertrophy or LBB with elevated cardiac markers **in 2 continuous leads**
* ST elevation \> 2mm in males, \> 1.5 mm females
* new onset BBB
1. Labs (troponin!!!! cardiac specific, CK-MB, myoglobin [earliest marker for cell injury but not cardiac specific)
2. ECHO
47
Acute coronary syndrome
consists of:
* unstable angina
* NSTEMI
* STEMI
48
STEMI treatment:
* aspirin 325mg chewable tablet
* go to PCI center w/in 90 mins
* start fibrinolytic therapy w/in 30 mins if transfer takes longer then 2 hrs
* reperfusion therapy w/in 12 hrs onset
* post PCI: dual anti-platelet therapy (P2Y12 receptor inhibitor/Plavix and aspirin x 30 months)
* BB w/in 24 hrs
* ACE, CCB
* nitrates
49
Post MI
* future risk of CV events
* f/u cardiac rehab
* assess med compliance, SE, sx's, risk factors, comorbidities
50
non invasive tests/biomarkers for CAD testing
C- reactive protein, interleukin -6, monocyte macrophage colony stimulating factor
51
Cardiac testing: C-reactive protein can be used in who for what?
* ASYmptomatic men 50+/women 60+ with LDL \< 160 if statin therapy is needed
* assesses CVD risk
52
Cardiac testing: ankle brachial index (ABI)
assess intermediate risk for subclinical CVD
53
cardiac testing: CACS
coronary artery calcium scoring
0: normal
10: low
400: high
r/t to plaque burden, high radiation exposure
54
cardiac testing: exercise tolerance test/stress test NOT in who?
DON'T DO IN ASYMPTOMATIC PPL WITH NO HX OF REVASCULARIZATION
55
cardiac testing: exercise tolerance test/stress test indication & results?
* detects CAD in pt's with angina or dyspnea on exertion who are at intermediate risk of ACS
* first line testing
* predicts future cardiac events/functional capacity
* normal ECG response: **isoelectric ST segment during exercise and recovery**
* **positive ETT if horizontal/downsloping ST segment depression of 1 mm**
* non dx if can't reach target HR [220 - age], unless there are ST changes before max HR reached
* OR exercise induced hypotension (SBP falls 20+ any point during exercise)
56
what causes lowered specificity of an exercise tolerance test?
* prior MI
* BBB
* conduction abnormality
* pacer
* pre excitation syndrome or inability to exercise
57
Exercise TT medication management before ETT
if ETT ordered d/t angina, ask cardiologist if should stop BB 1-2 days before test
if ETT is to see current pharm regimen is effective → continue BB
58
contraindications to exercise TT
ABSOLUTE: active endocarditis, HF, MI past 2 days, can't exercise, persistent stable angina, uncontrolled arrhythmias, heart blocks, aortic stenosis
relative CI: Complete heart block, cardiomyopathies, recent stroke/TIA, severe HTN, tachyarrhythmias
59
indications to *add* nuclear/ultrasound imaging to exercise TT
* **Left ventricle hypertrophy with ST segment and T wave abnormalities on resting ECG**
* **baseline ST/T wave abnormalities on resting ECG**
* recent MI
* use of digoxin
* Wolff-parkinson white syndrome, BBB, vent pacemaker
60
cardiac testing: exercise echocardiography
abnormal left ventricular EF or wall motion abnormalities using dobutamine
61
pharmacologic stress test
* for those that can't exercise/treadmill
* use coronary vasodilators (dipyridamole (Persantine) and adenosine and inotropic chronotropic (dobutamine) [reversed with aminophylline] to unmask variations in flow NOT ischemia
* assess effective coronary flow reserve
* ECG 20% show angina
62
Types of Heart failure
* HF with **reduced** EF \< 40%
* systolic HF
* can't contract/empty = decrease CO
* HF with **preserved** EF _\>_ 50
* diastolic HF
* impaired vent filling/relaxation
* HF with mid range LVEF 40-49%
* sx's both systolic and diastolic HF
63
left side HF vs right sided HF symptoms
* **dyspnea and fatigue**
* **sx's SUBLE due to fluid overload in body**
* Left sided HF: **fatigue dyspnea,** orthopnea, paroxysmal nocturnal dyspnea, cough, s3 or s4 heart sound, displaced apical pulse, **crackles if pulmonary edema**
* R sided HF (advanced L sided HF): LE edema, fatigue, exercise interlace, JVD, nocturia, ascites, hepatomegaly, nausea, S3 heart sound
64
HF compensations
* higher renin and adolsterone - Na retention = increases CO (give ACE/ARB)
* adrenergic to boost contractility (give BB)
* ventricular remodeling = dilation and thinning, worsens HF
65
NY Heart Association Functional Classification (based on Sx severity): Class 1
no limitations - asx with activity and rest
66
NY Heart Association Functional Classification (based on Sx severity): Class 2
* slight limitation. comfortable at rest
* Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath)
* ex: sx's occur after climbing 1 flight of stairs but pt does not need to stop
67
NY Heart Association Functional Classification (based on Sx severity): Class 3
* **Marked limitation of physical activity.**
* **Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea**
* **ex: pt can't climb 1 full flight without stopping/ need break**
68
NY Heart Association Functional Classification (based on Sx severity): Class 4
* inability to carry on any physical activity without discomfort and sx at rest
* ex: pt can't climb more than 1 step or sx start when grooming
68
NY Heart Association Functional Classification (based on Sx severity): Class 5
* inability to carry on any physical activity without discomfort and sx at rest
* ex: pt can't climb more than 1 step or sx start when grooming
69
ACC/AHA heart failure stages: Stage A
* high risk of HF
* NO SX's or STRUCTURAL changes
* ex: pt with HTN, obesity, DM
70
ACC/AHA heart failure stages: Stage B
* STRUCTURAL changes but no sx's
* ex: hx of MI with some remodeling, asx valvular heart disease, preheart failure
71
ACC/AHA heart failure stages: Stage C
* **structural changes AND symptoms**
* **hx of sx's of HF or current**
72
ACC/AHA heart failure stages: Stage D
* ADVANCED structural changes
* symptoms at REST (despite max medical therapy)
* refractory HF (recurrent fluid overload, hospitalizations)
73
Framingham criteria for diagnosing Heart Failure
Need 2 major OR 1 major + 2 minor:
* major:
* acute pulmonary edema
* cardiomegaly
* hepatojuglar reflux
* neck vein distention
* paroxysmal nocturnal dyspnea/orthopnea
* minor
* ankle edema
* dyspnea on exertion
* hepatomegaly
* nocturnal cough
* pleural effusion
* tachycardia \> 120 HR
74
HF workup
* CBC
* serum electrolytes
* Ca, Mg,
* BUN/Cr
* glucose
* lipids
* TSH, UA
* **BNP**
* N terminal proBNP
75
when is Brain natriuretic peptide (BNP) secreted? useful for? increased/decreased in?
* secreted by ventricular myocardial cells in response to elevation in END DIASTOLIC pressure and volume
* **higher sensitivity than specificity → can rule out HF**
* increased with age, ACS, anemia, COPD, pulmonary HTN
* lower in obese pt's
* if pt on ARNI [**Sacubitril/valsartan (Entresto)]**, draw **pro BNP** instead
* BNP \> 50 = dx early HF in high risk pts
76
ECHO
* most effective tool in HF assessment
* assess ventricle thickness, function, EF, valve dz, regurg/stenosis, size, wall motion
77
if pt has HF with reduced EF NEW ONSET
send to cardiology!
78
how likely is HF with normal BNP and normal echo?
unlikely!
79
always r/o what with new onset of heart failure?
ACS!
80
heart failure management
* **NO CCB, NSAIDs**
* **Na restriction, weight loss, med compliance**
* **hospitalization with new onset HF w/ sx/s fluid overload, suspect infarction, pulmonary edema with low O2 sats, unstable pts**
* assess for obstructive sleep apnea
81
HF med management
target RAAS system!
* diuretics (relieve congestion): HCTZ or Loop
* titrate up if \> 5lb gained in 2 days
* treat OSA, anemia, electrolyte imbalances etc
82
Stage A HF management
statin, BP \< 130/80, control arrhythmias (BB, amio), manage diabetes
83
Stage B HF management
* BNP screening
* treat BP w/ ACEI/BB (carvedilol, metoprolol, bisoprolol)
* vascular repair if needed
* consider ICD placement if LVEF \< 35%
84
Stage C HF management
\*classify pt as either reduced/systolic HF or preserved/diastolic HF
* **systolic/R: BB, ACE-i/Arb/ARNI, thiazide/loop, aldosterone antagonist**
* **monitor renal, Cr, KCl**
* hydralazine w/ isosorbide
* ivabradine
* digoxin
* ICD (if EF\< 35%)
* **diastolic/P: lifestyle, _diuretics_, treat comorbidities (DM, HTN, CAD)**
85
Stage D HF management
consider LVAD/transplant
palliative care
86
when to refer for heart failure?
* sx's refractory to standard therapies
* new stable arrhythmias
* new coronary ishcemia on EKG
* ALL young pt's w/ dilated cardiomyopathy or worsening sx's
87
when to hospitalize HF?\*
* **new onset HF with signs of congestion/fluid overload**
* suspect infarction or ischemia
* pulmonary edema (pink frothy sputum)
* O2 \< 90%
* unstable pts
* ACS/MI
* new arrhythmia w/ hemodynamic instability
88
Peripheral artery disease (PAD) screening
* All over 65
* all over 50 with hx of smoking or diabetes
* all with suspected PAD sx's + non healing wounds
89
PAD hallmark sign and presentation \*
* discomfort with activity “tiredness”, “giving way”, “soreness” “pain”
* hallmark: intermittent claudication
* tightening, cramping pain from exercise and alleviated by rest
* calf most common, thigh, butt (iliac artery obstruction/Leriche syndrome)
* severe: pain @ rest/awaken at night (alleviated by gravity)
90
\*PAD exam
* **distal hairloss**
* **shiny skin**
* absent femoral pulses/femoral bruit
* muscle atrophy
* advanced:
* **dependent rubor** (pale with elevate for 30 secs, then when dependent, deep red ensues
* longer it takes for rubber to get = worse ischemia
* skin ulcers
91
PAD initial diagnostic & for whom?
* **resting arterial brachial index (ABI): portable doppler + sphygmomanometer cuff**
* used in pts with 1 or more of:
* exertion leg sx's
* non healing lower extremity wounds
* hx with PAD in 65 ys +
* sx in pt 50 yrs + with smoking hx or diabetes
92
ABI interpretation and scores
* ABI lower in affected extremity
* measure brachial artery with dorsals pedis and posterior tibial arteries
* **\<0.9: PAD**
* 0.75 - 0.5: claudication
* \< 0.5: rest with pain and/or tissue loss
* **1-1.3: normal**
* \>1.4: calcified arteries → further assess with toe brachial index
93
AAA screening
1 time in men 65-75 who ever smoked
94
PAD treatment/management
* stable claudication
* exercise, no smoking, HTN/HLD/DM tx, compression stockings if ABI \> 0.8
* train walk to point of pain the rest til pain subsides
* podiatry consult
* ALL pts get ASA or placid, ACE/ARB, cilostazol (improve walking distance)
* NO b complex vitamin
* if severe ischemia: arteriography (diagnostic), then angioplasty or surgery = refer to er
95
PAD complications
* **AAA!!!**
* non healing wounds/ulcers
* peripheral neuropathy
* renal artery stenosis
* infection
96
pericarditis can be from
* **bacterial or viral infection**
* autoimmune
* w/ MI
* isoniazid or hydralazine
* malignancy
97
pericarditis clinical presentation
* sudden onset sharp retrosternal chest pain radiates jaw neck, pleuritic in nature
* chest pain worse supine, relieved sitting up & leaning forward; worse with inspri/expiration
* pericardial friction rub 85% while sitting, leaning forward
* RUB DOES NOT CHANGE WITH INSPIRATION/EXPIRATION
98
pericarditis diagnostic criteria
2 or more:
* sharp pleuritic chest pain
* **diffuse ST elevation**
* pericardial friction rub
* new or worse pericardial effusion on ECHO (elevated inflammatory markers)
99
pericarditis workup
* EKG: diffuse ST elevation
* Send to ED
* CXR (size, r/o pulmonary etiologies)
* ECHO (normal or pericardial effusion)
* CBC w/ diff, ESR/CRP (eleva) troponin (elv)
100
\*pericarditis treatment
* low risk: no large effusion, stable, no fever → outpatient
* **NSAIDs (ibuprofen or indomethacin) MAX dose then titrate down over 3-4 weeks**
* f/u regularly recheck inflammatory markers and sx's
* if no improvement in 1 wk, get hospitalized and refer to cardiology for further eval
