4_Diagnostic Approach to Chest Pain
What EKG clues will be present in Pericarditis? Antiplatelet Agents: Beware of ASA and other antiplatelet agents in patients with suspected ________ or other surgical pathology.
Diffuse concave ST-elevations/PR depressions dissection
Holter Monitor: Ambulatory, continuous ECG monitoring for ______-______ hours, most commonly used for patients with suspected _________, recurrent arrhythmias. Most devices are designed to record distinctly abnormal cardiac rhythms or be triggered by the patient to correlate to symptoms/activities. Usually the FIRST non-invasive cardiac rhythm assessment ordered for patients with FREQUENT, ________ symptoms of palpitations or unexplained syncope/near syncope or dizziness. Continuous ECG monitoring in the inpatient setting is usually referred to as telemetry. Event Monitor: Similar to holter monitoringg except patients may wear the monitor for an extended period of time (__________ days to _____ weeks) with virtually all ECG recording triggered by the patient when symptoms occur. IMPROVED diagnostic yield given increased duration of use. Patient-triggeredd recording systems may occasionally limit the ability to "capture" the arrhythmia. Usually reserved for patients with infrequent arrhythmia-type symptoms OR in patients with a non-diagnostic holter monitor evaluation. Implantable loop recorder: In essence, a near-continuous cardiac monitor procedurally placed in the SubQ tissue which is usually reserved for patiennts with INFREQUENT but concerning symptoms suggestive of a pathologic arrhythmia (i.e. unexplained syncope).
24-48 hours frequent daily 3 days to 3 weeks
History findings, what do they mean....... Pressure or squeezing pain=____________ Radiation to arm/jaw=______________ Associated diaphoresis or nausea=_____________ Associated dyspnea=_______,_________ or ____________ Sharp pain, worse with inspiration= ____________ or ______________ Sudden onset= ___________,__________, or_____________ Ripping or tearing pain=______________ Radiation to the back=________________ Associated neurologic deficits=______________ Constant boring pain=____________ or _________________
ACS ACS ACS ACS, PE, or PTX PE or PTX Dissection, PE, or PTX Dissection Dissection Dissection Esophageal rupture or pericarditis
Exercise Testing (treadmill) AKA GXTT Most commonly, the patient exercises by walking on a treadmill that progressively increases in spee and elevation while the ECG and vital signs are monitored. What treadmill protocol is most commonly used? Reliable results usually requires that the patient reachees at least ____% of their predicted maximum HR. Approximate sensitivity of 60-65% for CAD an approx. specificiy of 80-85% for CAD. What is the formula to calculate a target HR? The general considerations for most patients is that: exercise will be done on a treadmill or stationary bike, coninuously monitored ECG, and BP checked at intervals. The test will occur until any the following occurs? (4) The GXTT is used to assess: Risk of cardiovascular event, Long term prognosis, Exercise capability, Assist in therapeutic decision making, or localized area of ischemia for further treatment. What is an abnormal test defined as? (3) "Markedly" positive test findings include: Ischemic ECG findings within ____ min or exercise or persist ____ min after stopping exercise. ST Depression >2mm ______ blood pressure decreases during exercise High grade ventricular arrhythmias develop PT unable to exercise for at least 2 min because of cardiopulmonary limitations
Bruce 85% 220-age Angina, signs of myocardial ischemia on ECG, Target HR is acheived (85% of max HR), or the patient becomes fatigued Clinical parameters (i.e. "index" chest pain) OR Electrical parameters (horizontal ST segment depression >1mm) OR Both 3 min; 5 min systolic BP
What CXR findings will show a widening mediastinum, "globular" heart, or absent lung markings on one side?.......see pic What condition on CXR will show cephalization of vessels, interstitial edema (peribronchial cuffing, Kerly B lines), Alveolar edema (air bronchograms), Pleural effusions? What condition on CXR will show a poststenotic dilatation of the pulmonary artery? What condition on CXR will show a poststenotic dilatation of the ascending aorta? What condition on CXR will show LV dilitation and a dililated aorta? What condition on CXR will show a left atrial dilatation and signs of pulmonary venous congestion? What condition on CXR will show left atrial dilatation, LV dilatation, signs of pulmonary congestion is acute MR?
CHF Pulmonic valve stenosis Aortic valve stenosis Aortic regurgitation MS MR
Magnetic Resonance Imaging (MRI) is AKA ____________ (CMR). There is limited utility in common primary care management of cardiology-related issues. What is MRI best for differentiating ________ even without contrast? Similar indications for CMR as for CT but offers great potential for evaluation during a single comprehensive exam: assessment of function, perfusion, viability, tissue characterization, blood flow, morphology. There is increased cost but has high-resolution imaging. CMRA= coronary angiography is a non-invasive contrast-free angiographic imaging modality. It has high sensitivity and accuracy for CAD in the LMCA and proximal midpoints of three major coronary vessels. It is also useful for coronary artery ________ abnormalities. A Contrast enhanced MRI is when _________ is administered via IV to find infarcted myocardium and differentiate between impaired (reversible) and infarcted (non-reversible) tissue damage.
Cardiovascular magnetic resonance Differentiating tissues congenital Gadolinium
A heart score of 0-3 occurs in 32% of patients and has a 1-2% MACE....what is the recommended management? (1) This is a low risk patient! A heart score of 4-6 occurs in 51% of patients and has a 12-17% MACE...what is the recommended management? (3) This is a moderate risk patient! A heart score of 7-10 occurs in 17% of patients and has a 50-65% MACE...what is the recommended management? (3) This is a High Risk Patient!
Discharge Observe, risk reduction (BP reduction, Glycemic control, Lipid reduction, Smoking cessation, Weight loss) ASA, , noninvasive testing (Stress test, Coronary CT angiography, Stress Echo....all are about 80-85% sensitive and can rule out in low-moderate risk patients but not adequate for high risk patients) Admit, medical management (AACAA and risk reduction), consider early invasive testing, the gold standard for high risk patient diagnosis is serial troponins q4-6 hr, serial ecgs q 10-15 min, consider early coronary angiography.
What is our Non-Invasive Diagnostic Studies? (7) What is our Invasive Diagnostic Studies? (5) Chest Pain is Always an Emergency: Stabilize your patient if needed--CABs Obtain rapid and focused H&P Order essential tests at the same time Recognize conditions requiring emergent/treatment Alleviate your patients pain If you are worried about your patient do OMI....if the O2 is <94% use a nasal cannula 2-4 L/min, if you use a NRB use ___-____ L/min. Then order a ECG and CXR. Address abnormal vital signs. Address severe pain or distress.
EKG, CXR, CT, Echo, Trans-thoracic echo (TTE), MUGA, Holter & Event Monitor, Cardiac Stress test (Exercise/EKG only) Transesophageal echocardiography (TEE)--requires sedation/intubation in the OR, Cardiac stress testing (IV medications), Cardiac cath, Electrophysiologic studies, Implantable monitor 12-15 L
Computed Tomography (CT): What can a CT evaluate? (4) A CT has limited utility in common primary care management of cardiology-related issues. What are the 2 primary indications? Newer generation CT scanners ("ultrafast or electron-beam CT scanners (EBCT) and multi-slice scanners (MSCT) will likely increase the role of CT scanners. EBCT is the test of choice to evaluate for what cardiac diseases? An EBCT can also be used to evaluate cardiac tumors. Coronary artery calcification (CAC) as a means of cardiac risk assessment. Currently NOT broadly recommended as a means of screening asymptomatic patients for CAD. We do get a _______ score when performed appropriately which correlates with atherosclerotic plaque burden and is considered an cardiac risk predictor independent of other risk factors. What are the newer generation CT scanner Limitations? (4) What are the benefits? (3)
Great vessels, pericardium, myocardium, coronary arteries. Assessment of suspected great vessel problems including aortic anseurysm and aortic dissection in a STABLE patient. Pericardial anatomic abnormalities (i.e. pericardial thickening from chronic constrictive pericarditiis) TOC= pericardial diseases Agatstan score contrast dye, significant radiation exposure, artifact from patient motion, cannot provide degree of stenosis present quick, less invasive than angiography, relatively inexpensive
What is the HEART Score for chest pain patients? The main goal in determining the risk for ACS is to predict major adverse cardiac events (MACE).
History: i.e. a left sided, exercise increases intensity, atypical history= 3 points ECG: Age: Risk Factors: Troponin:
Cardiac Stress Test and When to Order: Intermediate probablity of CAD (15-85%): Typical angina in younger patients (<40 men, <60 women); Possible angina or non-anginal pain in older patients >40 men, >60 women) or in patients with multiple risk factors. Low probability of CAD (<15%): Possible angina in younger patients without a combination of multiple factors. High probability of CAD (>85%): Typical angina in older patients (>40 men, >60 women). Typical angina in patients with a combination of multiple risk factors (DM, smoking, hyperlipidemia----especially when all 3 are present). Which ones above get stress testing? General Cardiac Stress Test Considerations: What baseline EKG abnormalities will preclude ECG based testing? (6)
Intermediate (we can't determine if they are truly having issues) and Low risk (covering ourselves) High risk goes straight to the Cath Lab or admit LBBB, paced rhythm, non-specified IVCD, Any ST depression >1mm, LVH or digoxin therapy with any ST depression, or WPW-----these conditions will routinely have worsening of the ST depression during stress testing with tachycardia regardless of ischemia (high false positive)
Nuclear Studies: What is the Test of Choice for assessment of LV function? What are the advantages and disadvantages? What is the Test of Choice for assessment of myocardial perfusion and viability? What isotopes does this use? (3)
Multi-unit gated acquisition (MUGA) study--image blood through heart and great vessels. Localization and quantify ischemia/infarction. Assess myocardial metabolism. AKA Radionuclide Ventriculography (RVG). Primary purpose is to determine the left/right ventriicular ejection fraction (EF) through radiolabeling RBCs usually with technetium 99m. Advantages: highly accurate, provides info on RV and LV at the same time, not limited to body habitus, takes less than 30 min. Disadvantages: radiation exposure, no info on valvular structures, less accurate for patients with arrhythmias. Positron Emission Tomography (PET)--uptake proportional to blood flow, viability evaluated using radionuclide sugar solution. Dead or ischemic cells will not uptake the solution. Used to identify areas of impaired blood flow and injuried myocardium. nitrogen-13, fluorine-18, or rubidum-82
ACS affects 780,000 cases a year in the U.S. with a mean age of 68 y/o, males are affected >Females at a ration of 3:2, and 70% are NSTE. A new LBBB with a STEMI, NSTEMI, or UA increases the risk for MI 3 fold...what is the diagnostic criteria for a LBBB? (3) STEMI is diagnosed based on history and ECG....you do NOT needs labs or any other confirmatory tests to make the diagnosis. The patient has to have STE in 2 or more anatomically contiguous leads.
QRS >3mm (120 ms), Dominant S wave in V1, Dominant R wave without Q wave in lateral leads
Cardiac Stress Test: Stress testing is a valuable diagnostic and prognostic tool by inducing stress on the heart. There will be an increased myocardial oxygen demand that will induce clinical symptoms or ECG changes in a patient with impaired coronary artery blood flow. The primary goal is to determine the likelihood of clinically significant underlying CAD. Other purposes may include: prognostic assessment, functional capacity assessment, determining effectiveness of therapy, evaluating for exercise-induced arrhythmias or other symptoms. What are the absolute contraindications for ALL stress testing modalities? (7)
Recent STEMI </= 2 days High risk ACS -----> perform coronary angiogram Active HF (decompensated) Active endocarditis Severe Aortic Stenosis, Symptomatic HOCM Acute myocarditis or pericarditis Physical disability that precludes safe and adequate testing
What EKG clues will be present in a pulmonary embolism? Chest Pain Tests: How long do we have to get an ECG and how long do we have to get a CXR? Other Chest Pain Tests: Some patients need additional workup based on suspeced Dx. What should we order for ACS? (1) What should we order for a low-risk PE? (1) What should we order for a moderate to high-risk PE or dissection.....Stable patients only? (1) What should we order for pericarditis? (1)
Tachy, non-specific ST-changes, right heart strains/S1Q3T3(rare) ecg=10 min cxr=30 min serial troponin D-dimer Chest CTA (CT with angiogram) Echocardiogram
Cardiac Stress Test: GXTT Continued The ______________ Score based on 3 variables that can be used to estimate prognosis following an exercise treadmill test looks at exercise time (minutes based on this protocol) minus (5x maximum ST segment deviation in mm) minus (4x exercise angina). Exercise Testing (treadmill): Stress test modifications in general, are combined with a type of imaging modality are considered more sensitive and specific than routine exercise stress tests. The addition of the imaging modality also allows stress testing to be performed in patients who have a limitation to routine stress testing (i.e. complete LBBB). Stress Echocardiogram: Exercise stress test combined with pre-and post-exercise echocardiogram images. In addition to usual ECG criteria, identification of wall motion abnormalites on echo is a "positive" test. Echo allows estimationi of EF. Similar limitations as seen with routine echo (i.e. "bad windows"). For patients unable to exercise, the HR can be artificially stimulated by continuous IV infusion of _________ (a cardiac inotrope). Nuclear Stress Myocardial Perfusion Study: Exercise stress test combined with pre and post exercise nuclear myocardial perfusion images to determine areas of ischemia by comparison. For patients unable to exercise, dobutamine may be used as above as well as a "chemical stress test"...what 2 drugs do we use for this? These 2 drugs induce relative coronary artery dilation that approximates the effects of exercise without inducing an increased HR. Chemical stress tests are often necessary but are generally considered less preferable to actual exercise. Nuclear images allow estimation of EF. Limitations: potential artifact from obesity and breast tissue that prevents interpretation of the images.
The Duke Prognostic Treadmill Score Dobutamine Adenosine and dipyridamole
A true posterior infarction shows a Q wave and ST-depression in what 2 leads? A STEMI is STE in two or more contiguous leads....in leads V2-V3 STE needs to be >____ mm in men and >____ mm in women. All other chest/limb leads >1 mm. ST depression >2 mm for any reason (i.e. exercise, rest, whatever)= something serious going on. T wave inversion in 2 contiguous leads= something significant going on. The precorial leads are abnormal if >10 mm and >5 mm in the limb leads. A STEMI is treated with Percutaneous coronary intervention (PCI) and Thrombolysis....what 2 drugs can we use for thrombolysis? When two types of ACS do we never do thrombolysis therapy? Adjuncts to Revascularization: We use OMI MONA BASH C.....what is the AACAA approach?
V1 and V2 >2 men >1.5 women Streptokinase or TPA NSTEMI or UA ASA Antiplatelet agent (clopidogrel or ticagrelor) Consider oral BB if no contraindication Anticoagulation (UFH) Analgesia (Nitroglycerin or fentanyl....fentanyl doesn't decrease preload like morphine does)
What do these vital sign changes mean..... _____________= esophageal rupture or PE _____________= PE, tamponade, dissection, tension PTX ___________= ACS or PE causing dysrhythmia ____________= ACS involving conduction system ____________= PE, PTX _____________= Massive MI or PE, dissection, tension PTX Physical Exam: Pulmonary: Absent breath sounds= PTX Cardiac: Muffled heart sounds= tamponade; murmur=dissection/MI Vascular: pulse deficits=dissection; JVD=tamponade/PTX Extremities: Unilateral Edema=PE Neurologic: Focal deficits=dissection
fever Sinus tach Non-sinus tach bradycardia tachypnea HOTN
Ultrasound based imaging for cardiac structures: M-mode (1D single dimensional) is helpful for ___________. 2D defines cardiac structures relative to one another. 3D is the newest trans-esophageal Echocardiogram (TEE). Blood flow or function (Doppler)....what is beneficial about this? Two Types of Echocardiogram: Trans-thoracic Echocardiogram (TTE), this is non-invasive. Transducer is placed on anterior chest. Image quality may be significantly impaired by a "bad window" due to what? What specific information can a TTE provide? (6) Trans-esophageal Echocardiogram (TEE), requires an intubation in the OR. Used when more structural detail is needed. Transducer is placed in the esophagus immediately posterior to the heart via an endoscope. Primary advantage is increased sensitivity and specifity to detect anatomic abnormalities. Highly specific for what 4 conditions? PLEA Either type of Echocardiogram may be preformed with to identify an intracardiac shunt using what study? Echocardiogram Indications: ______________: suspected valvular heart disease, quantify regurgitation/stenosis. ____________: ventricular wall thickness and mass, Assessment of cardiac function, Estimated ejection fraction. ____________: Other suspected structural heart disease, Wall motion abnormalities post MI, Right ventricular function qualitatively. What other 2 cardiac pathologies?
measurement continuous evaluation of blood flow direction & velocity as well as turbulence body habitus (heavy people) Estimated Ejection fraction (calculated), Assesses for LV and RV dilation, Left Atrium size, Paradoxical septal motion, Valve septal motion, Valve structure assessment, Blood flow direction (regurgitation), timing, and velocity. prosthetic valve dysfunction, LA thrombus prior to cardioversion, endocarditis, aortic dissection bubble study Valvular lesions Ventricular assessment CAD Cardiomyopathy and Pericardial disease