L3- cardio- chest pain

initial assessment for undifferentiated chest pain

1) initial impression- sick or not sick?

2) assess primary survey: ABCs + vital signs

3) cardiac monitoring, IV access, administer O2 if pulse ox <90%

4) obtain 12 lead ECG WITHIN 10min of arrival

life threatening causes of chest pain

• acuter cornoary syndrome

• aortic dissection

• cardiac tamponade

• esophageal ruture

• pulm embolism

• pneumo

classic cardiac chest pain clinical manifestations

• retrosternal or left anterior chest location

• crushing, squeezing, tightness, pressure, heaviness

• radiation to left or right arm, neck, or jaw

• typically exertional, relieved by rest or nitro

• anginal oain lasts <15min

• associated sx

  • disphoreiss

  • dyspnea

  • n/v

nonclassic chest pain presentations

• stabbing, pleuritic, or sharp in quality

• well localized, positional

• brief, lasting only seconds

• constant pain lasting 12-24hrs or more

• exacerbated by mvmt, twisting or palpation

• reproducible pain

hx and PE of ACS

hx

• CP

• weakness

• nausea

• fatigue

PE

• diaphoresis

• ill appearance

hx and PE aortic disecction

hx

• sudden severe tearing pain to back

PE

• unequal

• abnormal pulses

• neuro deficit

hx and PE for pericardiits/tamponade

hx

• pleuritic chest pain

• dyspnea

PE

• muffled heart sounds

• JVD

• decreased BP

hx and PE for esophageal rupture

hx

• serve substernal CP after vomiting

PE

• hammans crunch

hx and PE fro pulm embolism

hx

• pleuritic CP

• SOB

• RF for VTE

PE

• tachy

• clear lungs

• leg edema

hx and PE for tension oneumo

hx

• sudden severe pleuritic CP

• dyspnea

hx

• unequal BS

• decreased BP

• tracheal dev

• JVD

ECG findings fro STEMI

• ST elevation (≥2mm) in ≥2 contiguous leads

ECG findings for pericarditis

• diffuse PR depression→ ST elevation look alike

ECG findings for cardiac tamponade

• low voltage QRS
  elecrtical alternans

ECG findings for PE

• sinus tach= MC

• S1Q3T3

• R heart strain

conventional cardiac tropnonins (I and T)

• biomarker o fhcoice for detectign myocardial injury

• detected within 4-6hrs

• peak 12-24 hrs, remain elevated 7-10days

• require serial measurements- time at 0 and 6 hours

• may be ekevated in non ACS dx

high sensitivity troponins

• preferred

• detect smaller myocardial injury within 1-2hrs

• serial measurements- test at 0/1h or 0/3h

other labs for chest pain

• CK-MB- not used too mych today

• BMP/CMP- evan electrolytes and renal func

• CBC- anemia can worsen ischemia, luekocytosis with PNA

• PT, PTT, INR- baseline for pts who will need anticoag, fibrinolytics (→ know how to adjust heparin if MI)

• D-dimer- possible PE

POCUS

• detects pericardial effusion or cardiac tmaponade

• asses cardiac contractility and left venttricular func

• eval for penumo

what imaging can be used to dx PE or aortic dissection

• chest CT

benign chest pain ddx

• anxiety

• MSK CP

• esophagitis

• costochondritis

• gastritis/GERD

acute coronary syndrome (ACS)

• cardiac disorders caused by acute myocardial ischemia

• classified by ECG findings

  • unstable angina

  • NTEMI

  • STEMI

unstable angina

• inadequate myocardial perfusion

• chest pain or anginal equivalent

• may shoe transient ST/T wave changes

• troponin = negative

• new onset angina limiting activity

• increasing freq.duration, occurs with less exertion

• rest angina >20min

acute myocardial infarction

• myocardial necrosis

• defined by elevated cardiac troponins

• NSTEMI- may have ST depression/T wave inversion; NO ST elevation

• STEMI- ST segment elevation ≥2 contiguous leads

atypical sx for ACS

• may not complain of chest pain!!

• SOB

• n/v

• disphoreiss

• back or abdominal pain

• dizz

groups at higher risk for atypical ACS presentations

• women

• elderly

• diabetes

• racial minorities

• pts iwth psych dz

no modifiable RF for chest pain/ACS

• older age

• male or postmenopausal female

• fhx of premature CAD

modifiable RF for CP/ACS

• HTN

• smokign

• hyperhcolesterolemia

• DM

• metabolic syndrome

• truncal obesity

• cocaine or stimulant

vital sign abnormalities in ACS

• HTN or hypotension

• tachycardia- increased sympathetic tone

• bradycardia- ischemia or infarction of conducting system

• S3 gallop

• new systolic murmur

response to nitro in ACS

• relieve angina, ut also esophageal spasm/GERD

  • no reliable

ECG and ACS

• obtain within 10 min of ED arrival

• look for ischemia and arrhythmias

• noraml ECG does NOT rule out ACS

  • could be unstable angina ot NSTEMI

• findings suggestive of ischemia in sx ots

• serial ECG 15-20,in interval for ongoing symtoms, compare with prior ECGs

inferior leads

• II, III, aVF

anterior/septal leads

• V1-V4

lateral leads

• V5-V6, I, aVL

inferior- coronary supply

• RCA

anteroseptal- coronary artery supply

LAD

anterior- coronary artery supply

• distal LAD

lateral-coronary artery supply

CFX

right- coronary artery supply

• RCA

posterior- coronary artery supply

• RCA or CFX

posterior MI

• occurs with inferior or lateral MIs

• changes in V1-V3

  • horizintal ST depression

  • tall R waves

  • upright T waves

• ST segment elevation with posterior leads

  • V7-V9

ACS lab testing

• cardiac tronpnins (hs I and T)= preferred

• AMI= acu=ove 99th percentile

• if neg, serial testing

• single cTn may rule out MI fro constant sx >8-12hrs

what score on the HEART calc will liekly lead to discharge

• <3

STEMI tx

• cardiac monitoring, large bore IVs, supp O2 if <90%

• antiplatelt therapy

  • aspirin 325mg

  • P2Y12 inhib (clopidogrel, pragurel, ticagrelor)

• analgesia.vasodilation

  • nitroglycerin SL for pain/ischemia

  • morphine only of pain not relieved by nitro

• anticoag

  • unfractionated heparin (MC) or LMWH to prevent re- hrombosis

    • heparin bolus right away of pt going straight to cath lab

• BB

  • oral metoprolol or atenolol within 24 hrs

  • avoid in HF, bradycardia, or heart block

• statin- high intensity

  • atorvastatin 80mg

nitro CI

• hypotension

• RV infarction

• aortic stenosis

• sildenafil

• caution with inferior MI

factors that influence choice of reperfusion for STEMI

• time from sx onset and time to PCI

• presence of cardiogenic shock (PCI preferred if possible)

• diagnostic uncertainty

• CI to PCI or finrinolytics

  • recent stroke, active bleeding, aortic dissection

• high risk comorbidities where reperfusion may be harmfu

PCI

• coronary stent or balloon angioplasty

• preferred STEMI refperfusion strategy

• goal

  • ≤90min from first medical contact at PCI able facility

  • ≤120 min if transfer from non- PCI facility

fibrinolytics

• if PCI unavailable within time guidelines

• only of ischemic sx <12hrs

• give within 30min of arrival time

• agents

  • alteplase, teneectaplase

• major risk- bleeding, escp intracranial

fibrinolytics CI

• hx intracranial hemorrohage, cerebrovascular malformation, or intracranial malignancy

• ischemic stroke in past 3months

• s/sx of aortic dissection

• active bleeding

• closed head fracture or facial trauma in past 3 months

tx for unstable angina or NSTEMI

• NO benefit from fibrinolytics

• aspirin 325mg

• nitro 0.4 sublingual

• antiplatelets: oral P2Y12 inhib (clopidogrel, prassugrel, ticagrelor)

• anticoag: UH or LMWH

• BB

  • given within 24hrs

  • if NO signs of heart failure, low cardiac output, severe reactive airway dz

• atorvastain 80mg as early as possible

• early invasive strategy

  • coronary angio and PCI if high risk

considerations for cocaine related ACS tx

• do NOT give BB

  • leads to unopposed alpha stimulation→ hypertensive crisis

• use benzodiazepines

venous thromboembolism (VTE)

• DVT and PE

• eti= virchow’s triad

  • endothelial injury

  • venous stasis

  • hypercoagulability

VTE risk factors

• prior VTE or advanced age

• obesity, preg

• malignancy

• inherited thrombophilia

• recent surgery, trauma

• prolonged immoobility

• smoking

• estrogen use

clinical features of deep vein thrombosis

• unilateral leg (or rarely arm) pain often indwelling catheter hx

• redness, swelling, warmth, tenderness

• dialted superficial veins, unilateral edema

• larger calf circumference (>3cm)

• homans sign (pain on passive dorsifelxion)

diagnostic approach to DVT

1) wells score to assess clinical pretest probability

2) low risk- order D dimer

• if neg→ NO further testing

• if positive→ order venous US

3) moderate or high risk- order venous US

• if positive→ treat

• if neg→ order D dimer

  • neg D dimer→ rule out DVT

  • positive D dimer→ repeat US in 1 week

first lien DVT mgmt

• DOAC (rivaroxaban, apixaban, dapigatran)

DOAC alternative fro DVT

• LMWH