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Flashcards in Chest Pain Deck (34)
1

6 life threatening causes of CP

ACS
PE
Aortic dissection
Esophageal rupture
Tension pneumothorax
Pericardial tamponade

2

Common non-life threatening

gastrointestinal
pulmonary (pneumonia or pleurisy)
chest wall syndromes (musculoskeletal pain)
psychiatric
shingles

3

the main trifecta of

a. Myocardial Infarction (cardiac ischemia)
b. Pulmonary Embolism
c. Aortic Dissection

4

exertion related pain that is consistent

Angina! (CAD)

i went out yesterday i usually walk three block before experiencing some discomfort


If fully occlude -->you’ve had a STEMI

5

main and other RF for Angina and CAD

males greater than 45
women >55
trasnfats and cholesterol
family
DM
HTN
Smoking


a. Stress, depression, insomnia
b. Amphetamine/cocaine use
c. ESRD
d. Connective tissue disease (SLE, RA)
e. Vasculitis
f. HIV/HAART medications
g. Trauma
h. Any condition where O2 demand exceeds supply (GI bleed, sepsis)

6

for stable angina, how do you target with questions

ask about pain
what were you doing yesterday and last week and last year

need to get a progressive HX of sxs

7

unstable angina differs from stable

class III or class IV

at leas than two blocks or one flight of stairs

significant atherosclerosis
keep for stress test or send to cardiology

8

when ruling out ACS what are you ruling out exactly

want to rule out a STEMI and NSTEMI

9

three patterns of STEMI

1. ST Depressions
2. T wave inversions
3. Wellens’ pattern

10

Definition of a NSTEMI

troponin increase in the absence of strict ECG criteria

11

2 Different causes for NSTEMI

2/3rds of the time supply/demand mismatches

can have this occur in sepsis with troponin release

can also be severely anemic and not have adequate oxygen delivery

1/3 occurs with occlusive myocardial infarction

12

NSTEMI tx

balloon, stent, thrombolitic

13

cardiogenic shock

hypotension and hypoprofusion associated with MI

due to MI or in the setting of cardiac dysfunction resulting form smaller events

14

AMI RF

EVERYONE
if you suspect MI get a troponin

15

common sxs with MI

CP does not radiate to legs but will radiate to back neck jaw shoulder and arms

sudden onset

can also see with dyspnea
syncope
nausea
vomitting
extreme weakness
diaphoresis

16

ATYPICAL sxs of MI seen in this population

Women,

diabetics (b/c of neuropathy and visceral nerves have been dulled)

elderly, barriers to communication

(language, dementia, altered mental status/psych)

17

atypical sxs of MI

N/V
cold sweats
SOB
fatigue
syncope
cold and clammy
back pain palpitations

18

what two medications can not be used to rule in or rule out cardiac related CP

NTG--> will relieve non related CP
GI cocktail--> will relieve MI

19

current STEMI standard criteria

any ST segment elevation of over 1mm in all leads other than V2 or V3

20

how to

II,III,AVF
I and AVL (lateral)

21

v1,v2,v3,v4 depression

inferior wall MI

22

all pts coming in with CP with suspicion of MI

i. IV – 2 large PIVs
ii. O2 – Nasal Cannula (could be harmful)
iii. Cardiac monitor – HR/rhythm + BP
iv. At least 2 sets of EKGs/biomarkers

23

b. STEMI Treatment

i.Cath lab as soon as possible

ii.Balloon angioplasty or stent

iii.May need bypass surgery if severe or multi-vessel disease

iv.Thrombolytics only if delay in transferring to STEMI center

24

NSTEMI/Unstable Angina Treatment

Aspirin - 162mg, NON-enteric coated, chewable
1.Mortality benefit

2.4-5% mortality benefit

Additional anti-platelet agents (e.g. clopidogrel/plavix preferred)

LMWH
small benefit
Nitroglycerin
1. Except in hypotension/R sided MI/recent phosphodiesterase use

analgesia-opiates

25

once admitted

1.High dose statin (Atorvastatin)

2.Beta blockers (after 24 hours) – don’t give in acute phase

`3.ACE Inhibitors (when stable)
VI. Disposition

26

when would you give BB

Not acute--> associated with cardiogenic shock

initially just plavex and ASA send to cath lab

maybe second day

27

AD high risk conditions

Marfans syndrome
connective tissue disease

family history of aortic disease

known aortic valve disease

recent aortic manipulation

28

high risk pain features of AD

chest, back or abdominal pain described as the followingL abrupt in onset, severe in intensity and ripping/tearing or sharp quality

29

High risk exam features for AD

evidence of a perfusion deficit (pulse deficit, systolic BP differential, focal neurologic deficit- in conjunction with pain )


murmur of aortic insufficiency

hypotension or shock state

30

what is the CM of AD

sharp,
knife like
ripping or tearing pain

syncope

on exam a pulse deficit
new diastolic murmur
focal neurological deficit


hypotension that may be related to cardiac tamponade, aortic valve regurgitation, acute myocardial infarction

31

whta type of focal neurological deficit would you expect to see in pt with AD

stroke, ALOC, horner syndrome, haorseness, acute paraplegia from spinal cord ischemia

32

most common population with AD

HTN (80%)
▪ most important
predisposing factor

MC Age 50-60y

33

AD diagnostics

CXR
▪ widening of mediastinum (classic)

MRI Angiography → Gold standard

CT with contrast
▪ becoming test of choice

Transesophageal echo

ADD-RS plus D-dimer
(low risk with neg D-dimer--> you're good)
either one high might need a negative D dimer

34

management of AD

ED management is lowering the HR and BP
HR<60 SBP 100-120
opiates for pain control

Surgical management
▪ Ascending or
▪ Descending with complications

Medical management
▪ Descending if no complications
- B-blockers 1st line: Esmolol, Labetolol