Professional Documents
Culture Documents
Johnston
Learning objectives
differentiate among the patient's symptoms as angina pectoris, atypical angina, or non-cardiac
chest pain.
document and present an appropriately complete medical history that differentiates among the
common etiologies of chest pain.
perform a physical exam that includes identifying the presence of dyspnea and anxiety, obtaining
accurate vital signs, and performing heart, lung, and vascular exams.
obtain a history of a patient with chest pain that: (1) contains information about those clinical
characteristics that are typical of angina pectoris, and (2) includes risk factors of coronary heart
disease.
propose appropriate laboratory and diagnostic studies based on patient demographics and the
most likely etiologies of chest pain.
discuss primary and secondary prevention of ischemic heart disease through the reduction of
cardiovascular risk factors (e.g. controlling hypertension and dyslipidemia, aggressive diabetes
management, avoiding tobacco, and aspirin prophylaxis).
propose appropriate anti-anginal medications when indicated and communicate potential adverse
reactions.
Knowledge
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Gastrointestinal
Pulmonary
Musculoskeletal
Psychogenic
Hyperlink "L">Cardiac"
Cardiovascular
causes of Chest
Pain
Symptoms
Signs
Vasospastic cause of
Variant Angina
Other abnormalities
Accompanied by transient ST
elevation on EKG.
Cocaine
Induced Chest
marks on lips and fingers from Tox screen positive for cocaine.
Pain
crack pipe.
Aortic
Dissection
Disease
pericardia! effusion on
echocardiogram.
2/14
Cardiac
Syndrome X
Myocarditis
women.
Hyperlink "L">Gastrointestinal"
Gastrointestinal
Causes of
Chest Pain
Symptoms
Signs
Other
Abnormalities
Biliary
Disease
Peptic Uleer
Gnawing, midepigastric pain.
Disease
3/14
Pancreatitis
Moderate to severe
midepigastric pain with
radiation to the back.
Elevated
amylase and
lipase
Epigastric tenderness
Hyperlink "L">Pulmonary"
Pulmonary
Causes of
Chest Pain
Pneumonia
Symptoms
Signs
Other
Abnormalities
Productive
cough, fever
lnfi ltrate on
CXR, elevated
WBC
Abnormal CXR
Possible
pleural effusion
onCXR
Abnormal CT of
chest, V/Q
scan, elevated
D-dimer
Acute pleuritic
Spontaneous
chest pain and
Pneumothorax
dyspnea
Pleurisy
Pleuritic chest
pain, dyspnea,
possible viral
syndrome
Pulmonary
Embolism
Pleuritic chest
pain associated
with dyspnea
Hyperlink "L">Musculoskeletal"
Museu loskeletal
Causes of
Chest Pain
Symptoms
Sharp anterior chest pain occurring at
Costochond ritis costochondral and costosternal
junctions. Possibly pleuritic
Signs
Other
Abnormalities
Tenderness to
palpation over chest
wall.
4/14
Rib Fracture
Tender over
affected rib
Myofascial Pain
points, often associated depression or
Syndromes
Herpes Zoster
sleep disorder
Rib fractures
seen on X-ray
Hyperlink "L">Psychogenic"
Psychogenic
Causes of
Chest Pain
Symptoms
Signs
Panic Disorder
Hyperventilation
Tachypnea
Somatoform
Disorders
Subjective complaints
outnumber objective
findings
Other
Abnormalities
ABGshows
low PC02
Atypical Angina
Patients who have diabetes, women, and the elderly are more likely to present with atypical
features. Occasionally they will present with only weakness or shortness of breath on exertion.
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Of those listed above, only age, male gender, current smoking, dyslipidemia, diabetes, and
hypertension are considered major traditional risk factors.
American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend
assessing major ASCVD risk factors every 4 to 6 years in adults 20 to 79 years of age who are free
fromASCVD.
For more required information about risk factors for ASCVD, read the MedU Cholesterol
Guidelines Module {http://www.med-u.org/cholesterol-guidelines) .
Alcohol in moderate quantities is beneficial for ASCVD but usually not recommended in this
country due to the problem of abuse and dependence. Use of greater than one alcoholic beverage
per day in women or two per day in men is not recommended because of other detrimental health
effects of alcohol, including liver disease and direct myocardial injury.
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Secondary prevention (preventing further disease in those with known disease) involves
avoidance of risk factors, more aggressive cholesterol lowering, and diabetic control. Certain
cardiovascular medications may be used as well, such as calcium channel blockers (CACBs) and
angiotensin-converting enzyme (ACE) inhibitors.
Several studies have demonstrated that CACBs are effective in the treatment of stable angina. In
2007, the American College of Cardiology/American Heart Association(ACC/AHA) stated their
preference of beta blockers (BB) over CACB based on BBs showing an improved survival rate in
patients with CAD. CACBs should be considered when BBs are contraindicated. The ACC/AHA
recommends patients with stable angina who have normal LV function be treated with ACE
inhibitors, but there is conflicting evidence that they reduce exercise-induced angina. Aspirin
prophylaxis is also an effective secondary prevention strategy.
Use of Fasting Lipid Levels to Further Assess ASCVD Risk and Determine
Appropriate Cholesterol Treatment Plan
The 2013 ACC/AHA Guidelines on Assessment of Cardiovascular Risk indicate that it is
reasonable to use Pooled Cohort Equations that require lipid data to estimate 10-year ASCVD risk
every 4 to 6 years in adults 40 to 79 years of age without clinical ASCVD.
Clinical ASCVD includes acute coronary syndromes, history of Ml, stable or unstable angina,
coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to
be of atherosclerotic origin.
To learn more about cholesterol management, see the required MedU Cholesterol Guidelines
Modu Ie (http://www. medu. orglcholesterol-guidelines).
Therapeutic lifestyle changes (TLC) should always be undertaken with or without concomitant
drug treatments. These lifestyle changes include a diet with saturated fat <7% of calories,
cholesterol intake <200 mg/day and increased soluble fiber intake. Exercise and weight control
are also a part of lifestyle change.
See the associated reference ranges in conventional and Sl units. {http://www.med7/14
Lab Values:
Conventional:
Sl:
Abdominal
obesity
1.70 mmoi/L
HDL
cholesterol
Blood
pressure
Fasting
glucose
>6,1 mmoi/L
A patient with a high pre-test probability should probably go straight to coronary angiogram,
because a negative stress test will not convince you the patient doesn't have a disease, A patient
with a low pre-test probability should not have a stress test, because it is unlikely to be positive.
Therefore, the best patient for a stress test is one with an intermediate pre-test probability.
Treadmill Exercise Stress Testing without additional imaging: Since the patient can
exercise and the EKG is normal this is one option, however some have argued that women
have higher rates of false positives and often cannot exercise to the extent needed for a
diagnostic test.
Pharmacologic Stress with imaging: This is an alternative if the patient cannot exercise to
the degree needed to produce a diagnostic result. Options include dipyridamole or
adenosine with nuclear imaging or dobutamine with echocardiography.
Angina
GERD
Some patients report pain from angina as 'burning,' although it is not the classic
descriptor.
Since women often report atypical symptoms, angina is a reasonable
diagnostic consideration in a woman with atypical symptoms prompted by
exertion.
In some patients shortness of breath is the only symptom of cardiac ischemia.
This is called an "anginal equivalent."
9/14
Aortic
dissection
Myocardial
infarction
I
Pulmonary
embolism
Hyperventilation
Acute
Musculoskeletal
pain
Pleurisy or
pneumothorax
Ventricular
tachycardia
MAY present with chest pain, but more commonly the symptoms
are palpitations, lightheadedness and syncope.
If VT is sustained, it may worsen to ventricular fibrillation --the most
common cause of sudden cardiac death.
Studies
Electrocardiogram
With an electrocardiogram, you can rule out an ST elevation Ml, look for evidence of prior
infarction (pathologic Q waves) and, occasionally, make other diagnoses such as pericarditis.
10/14
CBC
Electrolytes
useful for screening for kidney disease as this can contribute to heart disease
medications can adversely affect kidney function
Thyroid Stimulating Hormone
11/14
Management
Positive Stress Test Follow-up
Because the treadmill stress test is positive, the patient's chances of having true angina have
increased.
You could increase anti anginal medication and follow for symptom relief, or you could also order
cardiac catheterization with intervention to improve symptoms. The angiogram will allow the
cardiologist to directly visualize the coronary anatomy and potentially perform interventions on
stenotic segments.
Angina Treatment
Beta blockers decrease myocardial oxygen consumption by slowing heart rate and
decreasing blood pressure, and thus reduce angina.
Calcium channel blockers dilate coronary arteries and increase coronary blood flow while
also decreasing myocardial oxygen consumption.
Nitrates dilate systemic and coronary arteries but are primarily venodilators. The antiischemic effect of nitrates is due to systemic venodilation that leads to reduced preload and a
decrease in myocardial oxygen demand.
Exercise and dietary modification will be important in losing the weight but will also have other
advantages. Exercise will increase HDL cholesterol and dietary modification can lower total
cholesterol. decrease LDL cholesterol and decrease triglycerides. Decreasing dietary sodium
content will improve blood pressure control as well. Referral to a nutrition expert may be helpful in
achieving the weight loss and dietary objectives.
Hyperlink "L">Hydrochlorothiazide"
dehydration, hyponatremia, hypokalemia, renal dysfunction, increases serum uric acid which may precipitate gouty
attack
Hyperlink "L">Ciopidogrel"
bleeding
Hyperlink "L">Aspirin"
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gastritis, peptic ulcer disease, bleeding {especially when used with clopidogrel)
Hyperlink "L">Atorvastatin"
rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria; biochemical
abnormalities of liver function.
References
Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB, Gibbons R, Greenland P,
Lackland DT, Levy D, O'Donnell CJ, Robinson J, Schwartz JS, Shero ST, Smith SC, Sorlie P,
Stone NJ, Wilson PWF. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A
Report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines. Circulation. 2013 Nov 12.
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood
Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation
2013 Nov 12. [Epub ahead of print]
Steinhubl SR, Berger PB, Mann Ill J, et al. Early and Sustained Dual Oral Anti platelet Therapy
Following Percutaneous Coronary Intervention: A Randomized Controlled Trial. JAMA.
2002;288(19) :2411-2420.
Kastrati A, Mehilli J, SchOhlen H, et al., for the lntracoronary Stenting and Antithrombotic RegimenRapid Early Action for Coronary Treatment (ISAR-REACT) Study Investigators. A Clinical Trial of
Abciximab in Elective Percutaneous Coronary Intervention after Pretreatment with Clopidogrel. N
Eng I J Med 2004; 350:232-238
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