em 1.1 - cardio

What is the broad first mindset for chest pain in the ED?

Rule out life-threatening causes first, especially MI/ACS, aortic dissection, and PE.

What cardiac diagnoses can cause chest pain besides MI?

Stable angina, variant/Prinzmetal angina, pericarditis, tamponade, valvular disease.

What vascular diagnoses are on the chest pain differential?

Aortic aneurysm and aortic dissection.

What pulmonary diagnoses are on the chest pain differential?

PE, pneumothorax, pneumonia, COPD exacerbation.

What MSK causes are on the chest pain differential?

Costochondritis, rib fracture/trauma, strain/sprain.

What GI causes are on the chest pain differential?

GERD, pancreatitis, gallbladder disease, motility disorders.

What skin causes are on the chest pain differential?

Zoster and Candida.

🔴 Classic stable angina duration?

Lasts 5-10 minutes.

🔴 Classic stable angina triggers and relief?

Worse with exertion; relieved by rest or nitroglycerin, usually within 3 minutes.

🔴 Classic stable angina quality?

Aching, pressure-like, squeezing.

🔴Classic stable angina radiation?

May radiate to neck, jaw, arm, or hands.

Stable angina pattern over time?

Usually feels the same every time.

🔴 What is Prinzmetal angina caused by?

Cardiac artery spasm.

🔴 In Prinzmetal angina, CAD is absent in what fraction of cases?

About 1/3 of cases have no CAD.

🔴 When does Prinzmetal angina occur relative to rest/exertion?

It can occur irrespective of rest or exertion.

🔴 2 common triggers for Prinzmetal angina?

Tobacco and cocaine.

🔴 EKG finding during acute Prinzmetal attack?

Transient ST elevation (exactly like STEMI) only during the acute attack.

🔴 Classic aortic dissection patient?

Middle-aged or elderly hypertensive male.

🔴 Classic pain of aortic dissection?

Sudden, severe, tearing pain.

🔴 Classic location of dissection pain?

Retrosternal or midscapular pain.

🔴 Key associated findings that increase suspicion for dissection?

Neurologic deficit (not a necessary dissection but increases likeliness for dissection - carotid can cause stroke). Also hypotension, or pulse deficits.

🔴 Classic pericarditis pain?

Constant chest pain, worse lying supine, relieved by sitting forward.

🔴 Classic auscultation finding in pericarditis?

Friction rub.

🔴 Classic EKG findings in pericarditis?

Diffuse ST elevation (aka every lead) and diffuse T-wave inversion.

🔴 Tamponade chest pain character?

May be positional or pleuritic.

🔴 Tamponade symptoms? [2]

Dyspnea or palpitations.

🔴 Tamponade vital/physical findings? [4]

Tachycardia, hypotension, JVD, distant heart sounds.

🔴 Beck's triad?

Hypotension, JVD, muffled/distant heart sounds.

🔴 EKG clue for tamponade?

Electrical alternans.

🔴 Classic PE onset?

Sudden onset.

🔴 Classic PE chest pain?

Pleuritic chest pain.

🔴 Classic PE associated symptoms/signs? [6]

Hemoptysis, dyspnea, tachypnea, tachycardia, hypoxemia, DVT symptoms.

🔴 Classic PE EKG pattern taught in lecture?

S1Q3T3.

🔴 Pneumothorax lung exam?

Unilateral reduced breath sounds and hypertympany/hyperresonance to percussion.

🔴 Pneumothorax CXR clue?

Black area on CXR.

🔴 Tension pneumothorax red flag?

Deviated trachea.

🔴 1st sign of tension pneumothorax you'll porabbly see is

Anxiety.

Deviated trachea can also lead to JVD.

🔴 MSK chest pain clue?

Sharp pain worsened by movement of the chest wall.

🔴 Two MSK chest pain causes that improve with NSAIDs?

Intercostal/pectoralis strain and costochondritis.

🔴 GI - GERD/motility chest pain quality?

Burning or gnawing pain that can radiate to the throat.

🔴 GI - GERD chest pain triggers?

Meals and lying supine.

🔴 GI - GERD-associated symptom?

Belching.

🔴 Important GI cocktail warning in chest pain?

Do not diagnose based on relief with GI treatment because ACS can improve too.

🔴 Simple but important chest pain exam reminder?

Skin - look at the patient's chest before ordering an expensive workup. Ie. can be Zoster!

🔴 What are the 3 "can't miss" chest pain diagnoses emphasized in lecture?

MI, aortic dissection, and PE.

🔴 What should every chest pain interview always include?

The 7 attributes of the symptom.

🔴 4 Key Questions to ask for chest pain

1. Have you had SOB, nausea,

presyncope, diaphoresis?

2. Does it last 20-30 minutes at a time?

3. Is it worse with exertion and

relieved with rest?

4. How long did it take to get to its worst point?

Which 3 groups may present atypically with MI/ACS?

Women, diabetics, and elderly patients.

Compared with men, women with ACS have higher odds of what symptoms?

Ie. radiation to the jaw, "I just don't feel right."

Pain between shoulder blades, nausea/vomiting, and shortness of breath.

Compared with men, women with ACS are less likely to have what?

Chest pain and diaphoresis.

Chest pain physical exam should focus on what areas?

Heart, lungs, calves.

General appearance clues in chest pain?

Distress, pallor, obesity.

Why check calves in chest pain?

Look for DVT signs that would support PE.

Why check peripheral pulses/vascular signs in chest pain?

PAD signs or pulse deficits can shift concern toward vascular disease like dissection.

In addition to physical exam, what 2 questions must you ask?

Does it hurt when I press on it? Is this causing the pain you've been having? Are there gross neuro findings?

Does reproducible chest wall tenderness rule out ACS?

No.

🔴 First test all chest pain patients should receive?

EKG within 10 minutes of arrival.

🔴 If initial EKG is normal but symptoms are severe, what should you consider?

Repeat EKG in about 10-15 minutes.

Initial monitoring for chest pain patient? [5]

Vitals, cardiac monitor, oxygen monitor, IV access, cycling BP ~q15 min.

🔴 Initial ASA dose for chest pain/possible ACS?

325 mg chewable aspirin.

🔴 Major exception to giving ASA immediately in chest pain?

Suspected aortic dissection.

Sublingual nitroglycerin dose for chest pain?

0.4 mg SL every 5 minutes up to 3 doses.

🔴 When should nitroglycerin not be repeated?

If it is doing nothing or BP falls too low, especially SBP under 90.

In summary, what is the basic early ACS management order?

EKG → monitors/vitals/IV → aspirin → nitro if BP okay → pain control → repeat EKG if needed.

What are the 3 ACS "buckets"?

Unstable angina, NSTEMI, sudden cardiac death (STEMI).

What do UA, NSTEMI, and STEMI have in common disposition-wise?

They cannot be discharged or simply referred; they must be dealt with now.

Stable angina in the ED has what test findings?

🔴 Relieved with rest or nitro; Normal EKG and normal biomarkers/troponin.

Stable angina is suspected when chest pain seems cardiac but what is absent?

Evidence of acute ischemia.

Stable angina ED management after negative workup?

-These patients will be risk stratified after a thorough workup, then managed closely

and in the near future

-They may still go home or be observed in the hospital, though their follow up will be

based on your institution's guidelines or on cardiology consult.

Clinically, when this presents in the ER, it will be the patient with chest pain

without evidence of acute ischemia that we think may have a ___ ___.

🔴 Cardiac etiology.

🔴 ACEP outpatient follow-up timing for stable angina?

1-2 weeks.

🔴 AHA provocative testing timing for stable angina per lecture?

Stress/provocative testing within 72 hours.

🔴 Unstable angina definition: rest angina duration?

Rest angina usually more than 20 minutes.

Unstable angina definition: new onset?

New-onset angina limiting physical activity.

🔴 Unstable angina definition: increasing pattern?

Increasing angina that are:

- more frequent

- longer duration

- occurs with less exertion than prior angina.

Unstable angina EKG/troponin pattern?

No ST changes and negative troponins.

NSTEMI presentation compared with UA?

Similar presentation or anginal equivalent, but troponin is elevated.

NSTEMI key diagnostic difference from unstable angina?

Elevated troponin.

What term may combine UA and NSTEMI?

NSTE-ACS.

STEMI presentation?

UA symptoms or anginal equivalent plus ST elevation.

STEMI troponin?

Likely positive.

🔴 Two key tests nearly all ACS-suspected chest pain patients get?

EKG and troponin.

🔴 What EKG findings are assessed in ACS workup? [3]

ST elevation/depression, Q waves, T-wave inversion.

🔴 What does troponin indicate?

Cardiac muscle damage.

🔴 When does troponin peak per lecture?

After about 3 hours.

🔴 Approximate sensitivity/specificity of EKG and troponin for MI per lecture?

Each is about 90% sensitive and specific.

What fraction of MI patients may have a normal EKG?

About 1 in 10.

Can MI occur without elevated troponin initially?

Yes.

Can be early on in the course and just not in the bloodstream yet.

🔴 What fraction of EKGs that look like acute ischemia may not be MI?

About 1 in 10.

Why is an abnormal/ischemic-looking EKG not automatically an MI?

Because EKG is not perfect: about 1 in 10 EKGs that look like acute ischemia are not MI. Always interpret it with the patient's story, troponin, repeat EKGs, and old EKG comparison.

True/False - Elevated troponin only occurs due to MI.

False.

🔵 Troponin can also be elevated for other reasons.

Non-MI causes of elevated troponin emphasized in lecture? [4]

CKD, CHF, severe heart strain, PE.

What is the point of checking a delta troponin?

To see if troponin is rising over time, which supports acute myocardial injury/MI instead of one single unclear value.

Before dismissing elevated troponin as chronic, what 🔵 must 🔵 you document?

That it is chronically elevated in that patient.

If serial EKGs + troponins are normal in chest pain, what does that suggest?

Acute MI/active ischemia is unlikely → risk stratify; consider close follow-up ± stress test if stable angina suspected.

🔴 If EKG and troponin are both normal, what cardiac diagnoses may still remain?

Stable angina and unstable angina.

🔴 HEART score 1-3 means what?

Low risk; outpatient follow-up may be appropriate.

🔴 HEART score 4 or above means what?

Higher risk; cardiology consult/admission.

What is the caveat when interpreting HEART score?

Don't just look at the total number. EKG changes and troponin elevation are more concerning than points from age/risk factors alone.

🔴 What does the H in HEART score stand for?

History.