Chest Pain

History

  • Age
  • When did it start (cardiac cause – morning b/c of circadian rhythms), how did it start, what were you doing when it started
  • How long did it last
  • Type
  • Location, radiation (neck, arm, back)
  • Alleviating/aggravating (position – i.e. leaning forward in pericarditis)
  • Travel, clots, pregnancy, cancer
  • Risk factors (dyslipidemia, hypertension, diabetes, family history, smoking)
  • Associated symptoms (nausea, palpitation, diaphoresis, presyncope, SOB, cough, fever, calf pain)

Exam

  • Cardiac cause – ↑HR, ↑/↓BP, murmur

Immediate treatment

  • #1 ASA 10mg chewed
  • Morphine 5/10mg
  • O2 NP 2L
  • Nitro SL 0.3mg x 3 (5 minutes) – note: also relieves esophageal spasm
  • IV NS (maintenance or ↓)
  • Cardiac monitor



 

Investigations

  • EKG → on admission and when pain free (dynamic changes on EKG)
  • Troponin I → 6hr after onset of pain
  • CK
  • CBC – look for WBC
  • Lytes – especially K+
  • Creatinine
  • Urea – dehydration
  • Chest x-ray

Atypical presentation

  • Women
  • Elderly
  • Diabetics

Unstable Angina

  • Recent onset
  • Progressive/crescendo
  • Occurring ↑ frequency
  • Less extertion
  • More severe/prolonged pain
  • Less response to nitros
  • Pain at rest (lasting > 15 minutes)

Differential

  • Cardiac:
    • Angina (stable vs unstable)
    • MI
    • Pericarditis
    • Endocarditis
    • Dissection
    • Prinzmetal’s (vasospasm – Tx CCB)
  • Respiratory:
    • Pneumoni
    • Pneumothorax
    • Pulmonary embolus
  • MSK:
    • Costochondritis
    • Fractures
  • GI
    • GERD
    • Peptic ulcer disease (PUD)
    • Spasm, Achalasia, Nutcracker resophagus
    • Gastritis
  • Neurology
    • Herpes zoster
    • Neoplasm
  • Psychiatry
    • Panic attack

CCS classification for Angina

1 – only with strenuous, rapid or prolonged activity
2 – slightly limiting ordinary activity
3 – level walking at normal pace <1-2 blocks, <1 flight of stairs
4 – inability to carry on physical activity

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