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Heart Disease And Chest Pain

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Heart Disease And Chest Pain

  1. 1. Risk Factors and Chest Pain <ul><li>Risk factors can increase likelihood of chest pain being cardiac </li></ul><ul><ul><li>Regardless of the character (i.e. atypical MI) </li></ul></ul><ul><li>But the character of chest pain (MI or not?) carries the most weight in the initial workup </li></ul>
  2. 2. Chest Pain: More likely cardiac <ul><li>65 year old man </li></ul><ul><ul><li>with intermittent CP, no past medical history </li></ul></ul><ul><li>initial (most likely) dx? </li></ul><ul><ul><li>ischemic heart disease </li></ul></ul><ul><li>initial test? EKG, later a CXR </li></ul><ul><ul><li>after stablized/vitals </li></ul></ul><ul><ul><li>r/o worst case, noninvasive </li></ul></ul>
  3. 3. Chest Pain: Less likely cardiac <ul><li>45 year old woman </li></ul><ul><ul><li>with intermittent CP, no past medical history </li></ul></ul><ul><li>initial (most likely) dx? </li></ul><ul><ul><li>GERD </li></ul></ul><ul><li>initial test? EKG, later a CXR </li></ul><ul><ul><li>r/o worst case, noninvasive </li></ul></ul>
  4. 4. Risk Factors for CAD <ul><li>Mnemonic: “CHOSED A Boy Friend” </li></ul><ul><li>Cholesterol </li></ul><ul><li>HTN </li></ul><ul><li>Obesity </li></ul><ul><li>Smoking </li></ul><ul><li>Exercise </li></ul><ul><li>Diabetes </li></ul><ul><li>Age </li></ul><ul><li>Boy </li></ul><ul><li>Family history </li></ul>
  5. 5. Risk Factors: Cholesterol <ul><li>High LDL—most important </li></ul><ul><li>Low HDL—important </li></ul><ul><li>TRG—less important </li></ul><ul><ul><li>Less certain to be involved in dz </li></ul></ul>
  6. 6. Risk factors: Most common <ul><li>HTN : most common risk factor </li></ul><ul><ul><li>meds, regardless of #’s </li></ul></ul><ul><ul><li>Systolic = diastolic for risk </li></ul></ul><ul><ul><li>5X> than DM </li></ul></ul><ul><li>DM is a IHD equivalent </li></ul><ul><ul><li>Treatment implications </li></ul></ul>
  7. 7. “Most common cause of…”? <ul><li>these questions are about epidemiology and statistics </li></ul><ul><ul><li>answer is usually the most common dz </li></ul></ul><ul><li>hemoptysis? </li></ul><ul><ul><li>bronchitis, not TB/CA </li></ul></ul><ul><li>a-fib? </li></ul><ul><ul><li>HTN, not pheo/hypothyroidism/PE/MS </li></ul></ul>
  8. 8. Risk factors: Dependent <ul><li>Obesity </li></ul><ul><li>Exercise </li></ul><ul><ul><li>addresses metabolic syn </li></ul></ul>
  9. 9. Risk factors: Mortality <ul><li>correcting all of these reduce mortality </li></ul><ul><li>smoking : </li></ul><ul><ul><li>most effective in reducing mortality </li></ul></ul><ul><ul><li>10+cigarettes daily </li></ul></ul>
  10. 10. Risk Factors: Age and Family <ul><li>Age </li></ul><ul><ul><li>45 male </li></ul></ul><ul><ul><li>55 female </li></ul></ul><ul><li>Boy </li></ul><ul><ul><li>but if over 45, don’t count gender against him </li></ul></ul><ul><li>FHx: sudden death from MI </li></ul><ul><ul><li>55 male </li></ul></ul><ul><ul><li>65 female 1 st degree relative </li></ul></ul>
  11. 11. Chest pain: r/i most likely <ul><li>determines next step in management </li></ul><ul><ul><li>regardless of risk factors </li></ul></ul><ul><li>chest pain from MI </li></ul><ul><ul><li>nonpalpational, nonpleuritic, nonpositional </li></ul></ul><ul><ul><li>in real life 4% of the time can be any of above </li></ul></ul>
  12. 12. Chest pain: r/o most deadly <ul><li>What is ACS? </li></ul><ul><ul><li>Plaque rupture  superimposed thrombus  coronary occlusion  ACS </li></ul></ul><ul><li>Get an EKG to r/o MI! </li></ul><ul><li>most common cause of death in men (USA) </li></ul><ul><li>and woman (USA) </li></ul><ul><ul><li># of woman MI mortalities > # of deaths from next 4 most common causes of death </li></ul></ul>
  13. 13. Chest Pain: w/nonspecific signs <ul><li>Fever, SOB </li></ul><ul><ul><li>Present in all etiologies of chest pain </li></ul></ul><ul><li>Dyspnea </li></ul><ul><ul><li>Indicates severe hypoxia </li></ul></ul><ul><ul><li>Not in MI unless  CHF </li></ul></ul><ul><ul><li>Pneumothorax, PE </li></ul></ul>
  14. 14. Chest pain: pleuritic <ul><li>all start with a “P” and most are pulmonary </li></ul><ul><li>inflammatory/infectious </li></ul><ul><ul><li>pleuritis/pericarditis </li></ul></ul><ul><ul><li>pneumonia </li></ul></ul><ul><li>clot/bleed </li></ul><ul><ul><li>PE/DVT </li></ul></ul><ul><ul><li>Postpartum </li></ul></ul><ul><ul><li>Pneumothorax </li></ul></ul>
  15. 15. Chest pain: positional <ul><li>Pericarditis </li></ul><ul><ul><li>changes with leaning </li></ul></ul><ul><ul><ul><li>better leaning forward </li></ul></ul></ul><ul><ul><ul><li>worse leaning back </li></ul></ul></ul><ul><ul><li>pleuritic </li></ul></ul>
  16. 16. Chest pain: palpational <ul><li>costochondritis  chest wall tenderness </li></ul>
  17. 17. Stress Test <ul><li>Goal: Maximal heart rate </li></ul><ul><li>Needs to be able to exercise </li></ul><ul><li>Needs to have a readable EKG </li></ul>
  18. 18. Chest Pain: initial workup <ul><li>45 year old woman </li></ul><ul><ul><li>exertional , intermittent CP with no PMHx </li></ul></ul><ul><ul><li>shows up to your office without any CP </li></ul></ul><ul><li>Best initial test? EKG </li></ul><ul><ul><li>done for all CP to r/o MI </li></ul></ul><ul><li>NL EKG: next step? </li></ul><ul><ul><ul><li>Active CP  + EKG  enzymes </li></ul></ul></ul><ul><ul><ul><li>Nonactive, cardiac CP  stress test </li></ul></ul></ul><ul><ul><ul><li>Nonactive, noncardiac-type CP  GI evaluation </li></ul></ul></ul>

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