Transcript Chest Pain - Morning Report | a source for JPH students

Chest Pain
James Ignatius
Nicole Qaqish
7/19/2010
Classification
• Cardiac Vs Non-Cardiac causes
• Cardiac: Ischemic Vs Non-ischemic
pathology
• Ischemic: Angina, Myocardial Infarction
• Non-Ischemic: Pericarditis
• Non Cardiac: G.I (GERD, PUD),
Pulmonary (PE, Pneumothorax,
Pneumonia, Pleurisy, and Pul. HTN)
Chest Pain Questions
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“LIQUOR’D” mnemonic
L = location, (retro, substernal…
I Intensity (1 -10)
Q Quality (Sharp, Pressure, dull…)
U Upsetting/Aggravating Factors
O Onset
R Releiving factors + Radiation
D Duration
Angina
• Chest pain that occurs when the coronary
arteries do not deliver an adequate
amount of oxygen-rich blood to the heart
• Categorized as stable, unstable, and
Variant (Prinzmetal’s )
Stable Angina
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Clinical findings of stable angina:
Substernal , high pressure/heavy feeling
Duration from 1 – 5 minutes
Instigated by physical exertion
Relieved with rest or nitrates
Unstable Angina
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Clinical findings of Unstable Angina:
Occurs even at rest
unexpected
More severe and lasts longer than stable
angina, maybe as long as 30 minutes
• May not disappear with rest or use of
nitrates
Variant Angina
• Transient coronary vasospasm that is
associated with a fixed atherosclerotic
lesion (75%)
• Pt tends to be younger and in seemingly
good health
• Occurs at rest and and associated with
ventrcular dysrhythmias
• Nitrates and CCB’s are often effective
Diagnosis
• Resting EKG –
normal in pts with
Stable Angina, ST/T
wave changes in
unstable Angina and
Variant Angina
• Stress Echo-detect
ischemia, asses LV
function and valve
disease
Treatment
• Lifestyle changes
• Pharmacotherapy – Aspirin, Beta,
Blockers, CCB, Nitrates
• Revascularization (CABG)
Myocardial Infarction
• Interruption of blood supply which causes
necrosis of the myocardium.
• Atheromatous plaque ruptures into lumen
and thrombus forms on top of the lesion
causing occlusion
• MI has a 30% mortality rate.
Myocardial Infarction
• Clinical Features:
• Crushing substernal chest pain(usually
>30 minutes)
• Radiation to arms, neck, jaw, back (Left
side)
• Diaphoresis, Nausea, Vomiting, Dyspnea,
Syncope
Diagnosis
EKG changes:
ST elevation – transmural injury and can be
diagnostic of acute infarct
ST depression – Sunbendocardial injury
Q wave – evidence for necrosis, usually
indicative of an old MI. Not seen acutely
Diagnosis
Diagnosis
• Cardiac enzymes – Gold Standard.
• 3 sets q8 in 24 hours
• CKMB – increases within 4-8 hours, peaks
at 24hrs, and returns to normal 48 -72 hrs
later
• Trop I – More specific/sensitive than
CKMB.
• TropI falsely increased in Renal failure
Treatment
• Admit pt to CCU, Insert IV, , administer
oxygen, nitrates, morphine
• Aspirin, b-blockers, ACE Inhibitors reduce
mortality
• Lovenox can slow progression of
thrombosis.
• Cardiac Rehab- exercise + lifestyle
changes post MI
Pericarditis
• Inflammation of fibrous sac which covers
the heart
• Causes: Viral Infection (Coxsackie B,
Echovirus, Hep. A/B) MI, Uremia,
• Pts usually recover in 1-3 weeks
Pericarditis
• Clinical Features:
• Pleuritic chest pain that is
positional(worsened by lying down,
inspiration). Pain is releived by sitting up +
leaning forward
• Friction Rub – scratching, high-pitched
sound caused by rubbing of visceral and
parietal pleura
Pericarditis
• Diagnosis
• EKG – ST elevation and PR depression ,
then ST returns to normal, Twave inverts,
then returns to normal.
• Treatment: Treat underlying cause and
offer NSAIDS for pain
GERD
• Inaappropriate
relaxing of LES
causes backwards
flow of stomach
contents into
esophagus.
• Contributing factors:
ETOH, coffee, fatty
food intake, increased
age, and Hiatal
Hernia
GERD
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Clinical Features:
Burning, retrosternal pain after meals
Cough, nausea, vomiting
Hoarseness , sore throat
Reflex saliva hypersecretion
GERD
• Diagnosis:
• Endoscopy w/ Biopsy- Can detect cancer
complication or GERD
• 24 hr pH monitoring of LE – Gold
Standard. Highly specific/sensitive
GERD
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Treatment:
Phase I- diet changes + antacids
Phase II – Add H2 blocker (Ranitidine)
Phase III – Switch to PPI if symptoms
don’t resolve
• Phase IV – Add pro – GI motility Agent
(bethanechol/metoclopramide)
• Phase V – combo (H2 or PPI) + BTH/MET
Peptic Ulcer Disease
• A peptic ulcer is erosion in the lining of
the duodenum.
• Causes: H. pylori infection, NSAID,
Zollinger-Ellison syndrome, Smoking,
Stress
• Clinical Features:
• Epigastric pain that is achy
• Nausea, vomiting, weight loss, Upper GI
bleed
Diagnosis
• Endoscopy is most accurate test
• Histological evaluation of endoscope
biopsy – Gold Standard for H. pylori
infection
• Urease Breath Test – Shows active
infection, and efficacy of antibiotic therapy
• Serum gastrin- specific test for ZE
Syndrome
Treatment
• Lifestyle mods(Reduce smoking,stress,
ETOH, NSAID) No food before bedtime!
• If H. pylori is present use Triple or
Quadruple therapy
• Triple ( PPI + 2 antibiotics)
• Quadruple (PPI + Peptobismol + 2
Antibiotics)
Treatment
• H2 blockers help with ulcer healing
• Surgical intervention need for
complications of PUD like bleeding,
perforation
Case Study
• A 30 year old woman comes to the clinic
complaining of chest pain. For the last 2 years,
she has had intermittent nocturnal chest pain
that lasts up to 10 minutes. The pain is
substernal and radiates to her throat. It is 6/10
and wakes her up from sleeping. She has mild
nausea and a clammy feeling. In the past, she
has used antacids and PPI which did NOT help.
Aerobic exercise sometimes instigates this pain.
Case Study
• She reports being quite healthy except for
having Raynauds phenomenon in winter
and migraines treated with sumatriptan.
Social history is remarkable for cocaine
use. Vital signs and physical exam are
unremarkable. Holter monitor study is
arranged. What findings would be most
likely evident during an episode of her
chest pain?
Case Study
• A) PR segment depression
• B) Normal electrocardiographic tracing
• C) Prolonged QT interval with increased
duration at night
• D) Transient St elevation in inferior Leads
Answer
• D) This patient has a classic presentation
of Variant Angina, which is caused by
coronary vasospasm that induces
transient ischemia and ST elevations.
Patients are usually young women w/o
classic CVS risk factors. It usually occurs
at night and can be worsened by cocaine
and serotonergic agents like sumatriptan.
Answer
• Vasospams can occur in any distribution
but tend to favor the right coronary artery
which supplies the inferior portion of the
heart
• A = Pr depression is indicative of
pericardits. Viral infection in Hx would
have been a clue and leaning forward in
bed would have produced relief.
Answer
• B= ST elevations and T wave changes are
associated with variant angina. EKG can
not be normal
• C= There is no reason to suspect QT
interval prolongation. Pts who have
syncopal episodes may have QT
prolongation and it would not worsen at
night.