ppt applied knowledge

1. Chest discomfort

2. • Most common cause of ER or clinic presentation
• 1st : Hemodynamically stable vs. unstable
• 2nd : traumatic vs. nontraumatic chest pain
• 3rd : life threatening conditions including (APTAT): ACS, PE, Tension
pneumothorax, Aortic dissection, Tamponade
• Cardiopulmonary vs. noncardiopulmonary causes
• Myocardial ischemia
• Most common cause is GI causes (40%), 1/3 are cardiac ischemia, 1/3 chest
wall disorders, the rest are pericarditis, PE, AS, …
• 15% have cardiac causes
• 2/3 of cases of chest pain get admitted

3. . Could the chest discomfort be due to an acute, potentially life-threatening condition that
warrants urgent evaluation and management?
Unstable ischemic
heart disease
Aortic dissection Pneumothorax Pulmonary embolism
2. If not, could the discomfort be due to a chronic condition likely to lead to serious
complications?
Stable angina Aortic stenosis Pulmonary
hypertension
3. If not, could the discomfort be due to an acute condition that warrants specific treatment?
Pericarditis Pneumonia/pleuritis Herpes zoster
4. If not, could the discomfort be due to another treatable chronic condition?
Esophageal reflux Cervical disk disease
Esophageal spasm Arthritis of the shoulder or spine
Peptic ulcer disease Costochondritis
Gallbladder disease Other musculoskeletal disorders
Other gastrointestinal conditions Anxiety state

4. • A 54-year-old man presents to the ER with chest pain. The pain is a
“squeezing” pain and is right behind his mid chest. The pain lasted for
about 5 minutes and radiated to his left shoulder. The pain stopped
before coming to the ER. He was working outside in the cold when he
felt the pain. His PMH is significant for DM and obesity. Physical
examination is noncontributory. What is your diagnosis? What
investigations would you order?

5. • A 65-year-old female presents to the ER with chest pain for the last 15
minutes. She states that the pain is a burning sensation in the
epigastric area and is 5 out of 10 in terms of severity. The pain
radiates to her neck. Her PMH is significant for DM, HTN and GERD.
Physical examination reveals an S3 sound with pulmonary crackles.
What are your differential diagnoses?
While the patient is in the ER her pain gets worse and does not stop. If
this was an ischemic cardiac pain, what do you think has happened?

6. • A 35-year-old man presents to the ER with severe chest pain. He has
been vomiting multiple times before coming to the ER. He is
screaming of pain and he vomited blood once.

7. • A 67-year-old man presents to the emergency room with chest
tightness. He states that he does not feel really a pain and it is more
like feeling anxious with chest tightness and shortness of breath.

8. • A 73-year-old man presents to the ER with a severe chest pain. He
describes the pain as “ripping”. His past medical history is significant
for HTN and smoking one pack a day for 40 years. His EKG is not
significant. His CXR shows

9. • A 34-year-old woman presents to the ER with severe chest pain. She
states that the pain is sharp and is 10 out of 10. Breathing makes the
pain worse. When asked to show the location of the pain she uses her
index finger and points at left sternal border. Her PMH is positive for
mitral valve prolapse and general anxiety disorder.

10. • Retrosternal with radiation to the jaw, neck, shoulder and arms
• Radiation to both arms
• Aching pain only in the jaw, neck, shoulder and arms
• Very localized pain shown by the tip of one finger
• Retrosternal could be an esophageal pain
• Abdominal including epigastric pain is usually to due a GI disorder
• Above mandible or below the epigastrium
• Severe pain radiating to the back
• Radiation to the trapezius ridge

11. • Exertional pain for about 10s
• Exertional pain for about a few minutes
• Very intense pain in a short period of time (PE, aortic dissection,
spontaneous pneumothorax)
• Constant pain for a few hours

12. • Prefer to rest, sit, or stop walking
• “warm-up angina” : relief from angina as they continue at the same or even a greater level of
exertion
• Positional pain or relief suggest a musculoskeletal etiology, pericarditis (worse in supine)
• GERD may be exacerbated by alcohol, some foods, or by a reclined position. Relief can occur with
sitting.
• Exacerbation by eating: peptic ulcer disease, cholecystitis, or pancreatitis.
• In severe coronary atherosclerosis, redistribution of blood flow to the splanchnic vasculature after
eating can trigger postprandial angina.
• Relief by antacids
• Relief by nitroglycerin is suggestive of but not sufficiently sensitive or specific for a definitive
diagnosis of myocardial ischemia. Esophageal spasm may also be relieved promptly with
nitroglycerin.
• A delay of >10 min before relief is obtained after nitroglycerin suggests that the symptoms either
are not caused by ischemia or are caused by severe ischemia, such as during acute MI.

13. • Associated symptoms including diaphoresis, dyspnea, nausea, fatigue,
faintness, and eructation can be the only symptoms especially in elderly
and women
• Dyspnea is important because it suggests a cardiopulmonary etiology.
• Sudden onset of severe SOB  PE or pneumothorax
• Hemoptysis may occur with pulmonary embolism, or as blood-tinged
frothy sputum in severe heart failure but usually points toward a
pulmonary parenchymal etiology of chest symptoms
• Syncope or pre-syncope  PE, aortic dissection, ischemic arrhythmias
• N/V more common with inferior MI (vagal stimulation)

14. Physical exam
• Unilateral absence of lung sounds
• Uncontrolled hypertension
• COPD
• Heart failure
• An unremarkable physical examination is not definitively reassuring
• Anxious, uncomfortable, pale, cyanotic, or diaphoretic
• Levine’s sign
• Body habitus, Marfan syndrome or the prototypical young, tall, thin
man with spontaneous pneumothorax.

15. • Significant tachycardia and hypotension  acute MI with cardiogenic shock, massive
pulmonary embolism, pericarditis with tamponade, or tension pneumothorax.
• severe hypertension or profound hypotenion  Acute aortic emergencies
• Sinus tachycardia is an important manifestation of submassive pulmonary embolism.
Tachypnea and hypoxemia point toward a pulmonary cause.
• Low-grade fever is nonspecific because it may occur with MI and with thromboembolism
in addition to infection.
• Lung exam  pulmonary edema ; primary lung diseases (pneumonia, asthma,
pneumothorax)
• Cardiac exam  JVP (pericardial tamponade or acute right ventricular dysfunction), S3 or
S4 (more common), systolic murmur of MR or VSD, AR murmur (dissection)
• Other murmurs like aortic stenosis or hypertrophic cardiomyopathy; Pericardial friction
rubs reflect pericardial inflammation.

16. • AbdominalLocalizing tenderness on the abdominal examination is useful in identifying a
gastrointestinal cause of the presenting syndrome. Abdominal findings are infrequent
with purely acute cardiopulmonary problems, except in the case of underlying chronic
cardiopulmonary disease or severe right ventricular dysfunction leading to hepatic
congestion.
• Vascular pulse deficits may reflect underlying chronic atherosclerosis, which increases
the likelihood of coronary artery disease. However, evidence of acute limb ischemia with
loss of the pulse and pallor, particularly in the upper extremities, can indicate
catastrophic consequences of aortic dissection. Unilateral lower-extremity swelling
should raise suspicion about venous thromboembolism.
• MusculoskeletalPain arising from the costochondral and chondrosternal articulations
may be associated with localized swelling, redness, or marked localized tenderness. Pain
on palpation of these joints is usually well localized and is a useful clinical sign, though
deep palpation may elicit pain in the absence of costochondritis. Although palpation of
the chest wall often elicits pain in patients with various musculoskeletal conditions, it
should be appreciated that chest wall tenderness does not exclude myocardial ischemia.
Sensory deficits in the upper extremities may be indicative of cervical disk disease

17. EKG
• EKG needed within 10 min of presentation
• ST elevation (immediate interventions)
• ST depression and symmetric T-wave inversions at least 0.2 mV in depth are useful for detecting
myocardial ischemia in the absence of STEMI and are also indicative of higher risk of death or
recurrent ischemia
• Serial performance of ECGs (every 30–60 min) is recommended in the ED evaluation of suspected
ACS.
• ECG with right-sided lead placement should be considered in patients with clinically suspected
ischemia and a nondiagnostic standard 12-lead ECG. EKG sensitivity for ischemia is poor (20% in
some studies).
• ST segment and T wave changes are seen in PE, ventricular hypertrophy, pericarditis, myocarditis,
electrolyte imbalance, and metabolic disorders.
• Hyperventilation associated with panic disorder can also lead to nonspecific ST and T-wave
abnormalities.
• PE  S(I)Q(III)T(III)
• Diffuse ST elevation and PR-segment depression can aid in distinguishing pericarditis from acute
MI.

18. CXR
• Pneumonia or pneumothorax
• Pulmonary edema may be evident
• Widening of the mediastinum in some patients with aortic dissection
• Hampton’s hump (wedge shaped infarction) or Westermark’s sign
(dilation of pulmonary artery branch before the embolus) in patients
with pulmonary embolism
• Pericardial calcification in chronic pericarditis.

19. • Initial biomarkers maybe normal even in STEMI.
• Cardiac troponin & CK-MB should be repeated in 3–6 h
• In patients presenting >2 h after symptom onset, a negative troponin may
be sufficient to exclude MI with a negative predictive value >99% at the
time of hospital presentation (if you use high sensitive methods)
• Myocardial injury is detected in a larger proportion of patients who have
non-ACS cardiopulmonary conditions than with previous, less sensitive
assays.
• D-dimer test for PE exculsion
• BNP for HF or pulmonary embolism after ACS

20. • Diagnosis is based on:
• typical symptoms, age, risk factors or history of atherosclerosis, EKG
and cardiac troponin.
• Stress test for low or selectively intermediate risk of ACS
• Patients who are unable to exercise may undergo pharmacological
stress testing with either nuclear perfusion imaging or
echocardiography

21. • ongoing chest pain a contraindication to stress testing
• Echocardiography is not a routine test for IHD. Abnormal regional wall
motion provides evidence of possible ischemic dysfunction.
• Echocardiography is diagnostic in patients with mechanical
complications of MI or in patients with pericardial tamponade.

22. • CT angiography is very sensitive for patients with a low-intermediate
probability for ACS
• It excludes aortic dissection, pericardial effusion, PE
• Cardiac magnetic resonance (CMR) imaging is used for pharmacologic
stress perfusion imaging
• Gadolinium-enhanced CMR can provide early detection of MI
• A useful modality for cardiac structural evaluation of patients with
elevated cardiac troponin levels in the absence of definite coronary
artery disease