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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
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What is an aortic dissection?
- Intimal tear that causes separation of intima from the aortic wall (aortic media)
- Formation of a false lumen
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What is the #1 risk factor for aortic dissection?
Hypertension (HTN)
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What kind of pain will a aortic dissection feel like?
Sudden severe "ripping/ tearing" pain
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What will you see on the X-ray for an aortic dissection?
- Widening of the mediastinum
- Aorta will be widened
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What is the gold standard for an aortic dissection?
Aortogram/ TEE
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What do you order first for suspicions of an aortic dissection?
- First = X-ray
- Then = CT
- Then = Vascular surgeon
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Pericarditis is a pleuritc chest pain. What does that mean?
Sharp, worse with inspiration
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How is the pain of Pericarditis relieved?
- By sitting forward
- Takes pressure off the pericardial sac
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Can you hear a friction rub with pericarditis?
Yes
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What are inferior leads on an ECG?
Lead 2, 3, and aVF
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What will you see in most leads in an ECG for pericarditis?
ST elevation
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What will you see in an Echo for pericarditis?
Fluid in between the sac
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What kind of murmur (systolic or diastolic) does this belong?
Aortic Stenosis
Mitral Regurgitation
Tricuspid Regurgiation
Systolic Murmur
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What kind of murmur (systolic or diastolic) does this belong?
Aortic Insufficiency
Mitral Stenosis
Diastolic Murmor
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What will cause a diastolic murmur?
Aortic ______ and Mitral ______
- Aortic Insufficiency
- Mitral Stenosis
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What will cause a systolic murmur?
Aortic ______ and Mitral ______ and Tricuspid ___________
- Aortic Stenosis
- Mitral Regurgitation
- Tricuspid Regurgitation
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What is the triad of symptoms for Aortic Stenosis?
- Angina
- Syncope
- CHF (dyspnea)
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What may an ECG show for an Aortic Stenosis?
LVH
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What kind of pulse will you see with an Aortic Stenosis?
- Parvus Tardus Pulse
- Weak, slow pulse
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What is Mitral Stenosis commonly associated with?
Hx of Rheumatic Heart Disease
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What kind of sound will you hear with a Mitral Stenosis?
Low-pitched diastolic rumble
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What will you see an on ECG for Mitral Stenosis?
LAH with enlarged P waves
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What is Aortic Insufficiency caused by?
Diseased valves or root dilation
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What are some of the symptoms like for Aortic Insufficiency?
Palpitations, chest pounding
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What is the pulse like for Aortic Insufficiency?
"Water-Hammer" Pulse (Corrigan)
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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
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Less than how long is unlikely to be cardiac in origin?
Less than 1 minute
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A Q wave in a Stable Angina clinically means..?
There was hx of MI
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Which part of the heart are we talking about when we say myocardial infarction (MI)?
Left Ventricle
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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
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95% of the time, infarctions are caused by..?
Atherosclerosis, plaque rupture, and thrombus formation
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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
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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)
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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
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What characteristics do findings on the ECG depend on for ischemia or infarctions?
- Duration
- Size - amount of myocardium affected
- Localization
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Reperfusion therapy is beneficial for STEMI or Non-STEMI?
STEMI (ST elevation myocardial infarction)
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Where is the ST elevation measured for a STEMI?
- J-point (junctional)
- Junction between S wave and ST segment
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How long would does it have to be, to be considered a ST elevation or depression?
1 mm or 1 block
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Are new significant Q waves reversible or irreversible?
Irreversible
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What does a persistent ST elevation beyond 3 weeks indicate?
Ventricular aneurysm
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If there are changes in ECG for Leads 2, 3, and AVF, where is the location of the infarct?
Inferior portion of LV
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If there are changes in ECG for Leads 1, V5, V6, and AVL, where is the location of the infarct?
Lateral portion of LV
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If there is a lateral LV infarct, which leads will be different?
1, V5, V6, and AVL
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If there is a inferior LV infarct, which leads will be different?
2, 3, and AVF
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If there are changes in ECG for Leads V1, V2, V3, and V4, where is the location of the infarct?
Anterior portion of LV
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If there is an anterior LV infarct, which leads will be different?
V1, V2, V3, and V4
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How can you tell a Posterior infarct looking at an ECG?
ST depression at leads V1 and V2
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What artery supplies the lateral portion of the heart?
Circumflex artery
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What artery supplies the anterior portion of the heart?
LAD (left anterior descending) artery
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What artery supplies the posterior portion of the heart?
Right coronary artery
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What artery supplies the inferior portion of the heart?
Right coronary artery
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What are the 3 enzymes that will go up during cardiac injury?
- Troponin
- Creatine Kinase - MB
- Myoglobin
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A standard measurement of troponin is sufficiently sensitive more than how many hours after an injury?
6 hours
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When should you check for troponin levels for a cardiac injury?
At presentation and 6 hours later
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What is the preferred biomarker for the diagnosis of myocardial infarction and why?
Troponin
- 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)
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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
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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
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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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