2.8 Clinical Aspects and Different Types of Cardiac Chest Pain

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  1. What are some life threatening etiologies when presented with chest pain?
    • Acute MI
    • Aortic Dissection
    • Critical Aortic Stenosis
    • Pulmonary Embolus
    • Pneumothorax
    • Esophageal Rupture
    • Perforating Peptic Ulcer
  2. What is an aortic dissection?
    • Intimal tear that causes separation of intima from the aortic wall (aortic media)
    • Formation of a false lumen
  3. What is the #1 risk factor for aortic dissection?
    Hypertension (HTN)
  4. What kind of pain will a aortic dissection feel like?
    Sudden severe "ripping/ tearing" pain
  5. What will you see on the X-ray for an aortic dissection?
    • Widening of the mediastinum
    • Aorta will be widened
  6. What is the gold standard for an aortic dissection?
    Aortogram/ TEE
  7. What do you order first for suspicions of an aortic dissection?
    • First = X-ray
    • Then = CT
    • Then = Vascular surgeon
  8. Pericarditis is a pleuritc chest pain. What does that mean?
    Sharp, worse with inspiration
  9. How is the pain of Pericarditis relieved?
    • By sitting forward
    • Takes pressure off the pericardial sac
  10. Can you hear a friction rub with pericarditis?
  11. What are inferior leads on an ECG?
    Lead 2, 3, and aVF
  12. What will you see in most leads in an ECG for pericarditis?
    ST elevation
  13. What will you see in an Echo for pericarditis?
    Fluid in between the sac
  14. What kind of murmur (systolic or diastolic) does this belong?
    Aortic Stenosis
    Mitral Regurgitation
    Tricuspid Regurgiation
    Systolic Murmur
  15. What kind of murmur (systolic or diastolic) does this belong?
    Aortic Insufficiency
    Mitral Stenosis
    Diastolic Murmor
  16. What will cause a diastolic murmur?
    Aortic ______ and Mitral ______
    • Aortic Insufficiency
    • Mitral Stenosis
  17. What will cause a systolic murmur?
    Aortic ______ and Mitral ______ and Tricuspid ___________
    • Aortic Stenosis
    • Mitral Regurgitation
    • Tricuspid Regurgitation
  18. What is the triad of symptoms for Aortic Stenosis?
    • Angina
    • Syncope
    • CHF (dyspnea)
  19. What may an ECG show for an Aortic Stenosis?
  20. What kind of pulse will you see with an Aortic Stenosis?
    • Parvus Tardus Pulse
    • Weak, slow pulse
  21. What is Mitral Stenosis commonly associated with?
    Hx of Rheumatic Heart Disease
  22. What kind of sound will you hear with a Mitral Stenosis?
    Low-pitched diastolic rumble
  23. What will you see an on ECG for Mitral Stenosis?
    LAH with enlarged P waves
  24. What is Aortic Insufficiency caused by?
    Diseased valves or root dilation
  25. What are some of the symptoms like for Aortic Insufficiency?
    Palpitations, chest pounding
  26. What is the pulse like for Aortic Insufficiency?
    "Water-Hammer" Pulse (Corrigan)
  27. How long will an Ischemic Chest Pain last and how long will it not exceed?
    • Lasts 3-5 minutes
    • Doesn't exceed 20 minutes w/o causing MI
  28. Less than how long is unlikely to be cardiac in origin?
    Less than 1 minute
  29. A Q wave in a Stable Angina clinically means..?
    There was hx of MI
  30. Which part of the heart are we talking about when we say myocardial infarction (MI)?
    Left Ventricle
  31. What are 2 common causes of ischemia?
    • Narrowing or obstruction of a coronary artery
    • A rapid arrhythmia, causing an imbalance in supply and demand for energy
  32. 95% of the time, infarctions are caused by..?
    Atherosclerosis, plaque rupture, and thrombus formation
  33. What are the 5 ECG changes seen with ischemia/ infarction?
    • T wave peaking
    • ST segment elevation
    • ST segment depression
    • T wave inversion
    • Appearance of new/ significant Q
  34. What is the earliest change you'll see in an ECG when the arteries are occluded during an infarction?
    • Tall peaking T wave (Hyperacute)
    • Might not see it (minutes - hours)
  35. What is the order of the 5 ECG progression changes seen for an infarction?
    • Tall peaking T wave (Hyperacute)
    • ST Elevation
    • Q wave developing over
    • ST elevation with T wave inversion
    • T wave recovery
  36. What characteristics do findings on the ECG depend on for ischemia or infarctions?
    • Duration
    • Size - amount of myocardium affected
    • Localization
  37. Reperfusion therapy is beneficial for STEMI or Non-STEMI?
    STEMI (ST elevation myocardial infarction)
  38. Where is the ST elevation measured for a STEMI?
    • J-point (junctional)
    • Junction between S wave and ST segment
  39. How long would does it have to be, to be considered a ST elevation or depression?
    1 mm or 1 block
  40. Are new significant Q waves reversible or irreversible?
  41. What does a persistent ST elevation beyond 3 weeks indicate?
    Ventricular aneurysm
  42. If there are changes in ECG for Leads 2, 3, and AVF, where is the location of the infarct?
    Inferior portion of LV
  43. If there are changes in ECG for Leads 1, V5, V6, and AVL, where is the location of the infarct?
    Lateral portion of LV
  44. If there is a lateral LV infarct, which leads will be different?
    1, V5, V6, and AVL
  45. If there is a inferior LV infarct, which leads will be different?
    2, 3, and AVF
  46. If there are changes in ECG for Leads V1, V2, V3, and V4, where is the location of the infarct?
    Anterior portion of LV
  47. If there is an anterior LV infarct, which leads will be different?
    V1, V2, V3, and V4
  48. How can you tell a Posterior infarct looking at an ECG?
    ST depression at leads V1 and V2
  49. What artery supplies the lateral portion of the heart?
    Circumflex artery
  50. What artery supplies the anterior portion of the heart?
    LAD (left anterior descending) artery
  51. What artery supplies the posterior portion of the heart?
    Right coronary artery
  52. What artery supplies the inferior portion of the heart?
    Right coronary artery
  53. What are the 3 enzymes that will go up during cardiac injury?
    • Troponin
    • Creatine Kinase - MB
    • Myoglobin
  54. A standard measurement of troponin is sufficiently sensitive more than how many hours after an injury?
    6 hours
  55. When should you check for troponin levels for a cardiac injury?
    At presentation and 6 hours later
  56. What is the preferred biomarker for the diagnosis of myocardial infarction and why?

    • Because:
    • Increased sensitivity and specificity
    • Elevations are almost always specific for cardiac injury (CK-MB non specific for cardiac injury, since small amount is found in skeletal muscle)
  57. Why can't CK-MB (Creatine Kinase MB) be used for a biomarker for myocardial infarction?
    • Nonspecific for cardiac injury since small amount is found in skeletal muscle
    • Adds more cost, but no more clinical utility than cTn
  58. How do you treat an Unstable Angina or NSTEMI?
    • Give additional anti-platelet therapy
    • Give anticoagulant therapy
    • Optimal timing of cardiac catheterization and potential PCI (percutaneous coronary intervention) or coronary revascularization based on risk assessment
  59. How do you treat a STEMI?
    • Need to reperfuse!
    • Primary PCI w/in 90 minutes
    • Treat w/ fibrinolysis if PCI unavailable w/in 90-120 minutes, symptoms <12 hours, and no contraindications
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2.8 Clinical Aspects and Different Types of Cardiac Chest Pain
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