Questions and Answers
Which symptom is considered more specific to panic attacks rather than cardiac events?
What psychological source is recognized as a common cause of chest pain?
Which symptom can occur in both panic attacks and cardiac events, but often has different underlying causes?
Which feeling is commonly associated with both panic attacks and cardiac events?
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Which symptom is most concerning as it can mimic a heart attack?
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Which type of chest pain is characterized by pain reproducible with palpation?
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In cases of chest pain, which demographic is most likely to be associated with panic attacks as per DSM V criteria?
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What is the time frame within which treatment of Acute Myocardial Infarction significantly reduces mortality?
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Which condition is categorized as an 'acute' cause of gastrointestinal chest pain?
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Which type of chest pain might include symptoms such as cough, fever, and leukocytosis?
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Which type of vascular chest pain originates from the descending aorta and can extend both above and below the diaphragm?
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What percentage of malpractice litigation against emergency physicians is related to missed myocardial infarctions?
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Which of the following is NOT a respiratory cause of chest pain?
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What distinguishes unstable angina from stable angina?
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Which biomarker is indicative of myocardial injury but does not meet myocardial infarction criteria in unstable angina?
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Which treatment is NOT part of the MONA protocol for managing acute coronary syndromes?
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What is the primary purpose of cardiac catheterization in the management of unstable angina?
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What is a characteristic feature of STEMI compared to unstable angina?
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Which test should be ordered for suspected heart failure?
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What is the critical threshold for Troponin level indicating significant concerns?
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Which imaging test is first indicated for a high suspicion of pulmonary embolism (PE)?
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Which test is no longer commonly used for evaluating cardiac injury?
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What is the time frame in which Troponin rises after a cardiac event?
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What is the primary use of a D-Dimer test in patients with chest pain?
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What is the appropriate action if D-Dimer is positive in the context of PE?
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Which condition is NOT considered a cardiac source for chest pain?
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Which of the following is not a typical symptom of a STEMI?
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In STEMI diagnosis, which EKG finding is particularly important?
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What is the first-line treatment for a STEMI patient?
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What is the purpose of administering antiplatelet therapy during fibrinolysis?
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Which of the following is not included in the TIMI Risk Score?
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In the context of NSTEMI, which statement is correct?
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What is the typical course of treatment for pericarditis?
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Which diagnostic test is least likely to confirm cardiac tamponade?
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Beck's Triad is associated with which condition?
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Which timing is critical for administering fibrinolytics to achieve the best mortality benefit?
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What is a key difference between STEMI and NSTEMI?
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The HEART score is used to assess the risk of major cardiac events primarily in which type of patient?
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Which medication class is emphasized for all STEMI patients during treatment?
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Early diagnosis of myocardial injury in STEMI can sometimes be indicated by what finding?
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Study Notes
Importance of Evaluating Chest Pain in the Emergency Department (ED)
- Chest pain is the most common presenting symptom in the ED.
- Timely intervention in acute myocardial infarction (AMI) reduces mortality to 1.6% if treated within 70 minutes.
- The phrase "time is tissue" highlights the critical importance of rapid treatment.
- Missed myocardial infarctions are a leading cause of malpractice litigation against emergency physicians, accounting for 20% of malpractice costs.
Causes of Chest Pain
- Chest pain can arise from various systems, including:
- Cardiac
- Vascular
- Pulmonary
- Gastrointestinal (GI)
- Musculoskeletal (MSK)
- Infectious/skin
- Psychological
Cardiac Causes of Chest Pain
- Key cardiac conditions include:
- Arrhythmia
- Angina
- Acute Coronary Syndrome:
- Unstable Angina
- ST-Elevation Myocardial Infarction (STEMI)
- Non-ST-Elevation Myocardial Infarction (NSTEMI)
- Pericarditis
- Trauma/Tamponade
Vascular Causes of Chest Pain
- Aneurysms:
- Ascending aorta: > 5.0 cm
- Descending aorta: > 4.0 cm
- Aortic Dissection Types:
- Type 1: Ascending aorta to arch
- Type 2: Limited to ascending aorta
- Type 3: Descending aorta extending distally
- Pulmonary Embolism (PE):
- Massive: 5% of PE cases, hypotensive requiring pressors
- Submassive: 40% of PE cases, presenting RV strain/dilation/dysfunction
- Low Risk: 50-60% of PE cases
- Pulmonary Hypertension
Pulmonary Causes of Chest Pain
- Pleuritis: Similar pain to PE, differentiation requires labs and vital signs.
- Pneumonia: Symptoms include cough, fever, and leukocytosis.
- Bronchitis: Typically viral in origin.
- Pneumothorax: Characterized by hypoxia and absent breath sounds.
Gastrointestinal Causes of Chest Pain
- Conditions include:
- Gastroesophageal Reflux Disease (GERD)
- Food bolus/foreign body obstruction
- Esophagitis, esophageal rupture (emergent condition)
- Peptic Ulcer Disease
- Cholecystitis
- Pancreatitis
- Splenic infarct/injury
- Esophageal rupture may require GI and cardiothoracic surgery.
Musculoskeletal Causes of Chest Pain
- Costochondritis: Reproducible pain alleviated with anti-inflammatories.
- Radicular pain: May originate from cervical or thoracic spine.
- Trauma: Includes fractures, contusions, and muscle strains.
Dermatological/Infectious Causes of Chest Pain
- Herpes Zoster/Shingles: May present in active infection, prodromal, or post-herpetic stages.
- Infectious causes include cellulitis, abscess, and mastitis.
Psychological Causes of Chest Pain
- DSM V recognizes numerous signs of panic attacks that mimic cardiac symptoms:
- Palpitations and accelerated heart rate.
- Sweating and trembling.
- Shortness of breath; feelings of choking.
- Chest pain or discomfort, nausea, and abdominal distress.
- Dizziness and faintness.
- Chills, paresthesias, and feelings of unreality.
- Fear of losing control or dying.
- A thorough evaluation is essential regardless of the patient’s psychiatric history to rule out serious cardiac conditions.
Angina
- Angina Pectoris results from coronary heart disease causing chest pain during physical activity or stress.
- Typically predictable with episodes lasting under 5 minutes and relieved by rest or medications.
- Responds well to Nitroglycerin and can be prevented using ACE inhibitors, ARBs, beta-blockers, and calcium channel blockers.
- Unstable Angina, part of Acute Coronary Syndromes, occurs unexpectedly and persists longer, often not relieved by rest or medications, escalating the risk of myocardial infarction (MI).
EKG Changes and Biomarkers
- Transient EKG changes in unstable angina include ST segment depression, ST segment elevation, and T wave inversion.
- Troponin levels may be slightly elevated but do not meet criteria for MI.
Treatment Options for Unstable Angina
- Administer MONA (Morphine, Aspirin, Nitroglycerin, Oxygen), antiplatelet agents, and anticoagulants.
- Cardiac catheterization and Percutaneous Coronary Intervention (PCI) are essential for treatment.
- Coronary Artery Bypass Graft (CABG) may be performed based on severity.
STEMI
- STEMI, or ST Elevation Myocardial Infarction, results from the complete blockage of coronary arteries causing ischemia and myocardial injury.
- Symptoms: chest pain, radiating pain, shortness of breath, nausea, diaphoresis, and dizziness.
- Diagnosed through ST elevation on EKG (≥1mm in contiguous leads) and elevated troponin levels.
STEMI Work-Up
- Initial evaluation includes vital signs, EKG, and lab tests (CBC, CMP, troponin).
- Key EKG findings are ST elevation, new left bundle branch block (LBBB), and potential pathological Q waves.
STEMI Treatment
- Supportive care with MONA and medications like beta-blockers, statins, and ACE inhibitors.
- Definitive treatment options include PCI, CABG, and fibrinolysis, with fibrinolysis being less preferred.
NSTEMI
- Represents a heart attack without clear STEMI EKG findings, exhibiting similar symptoms.
- Diagnosed based on clinical risk factors, lack of STEMI EKG changes, and a rise in cardiac markers like troponin.
- Treatment includes supportive care, anticoagulation, and PCI without the use of fibrinolytics.
Pericarditis
- Characterized by inflammation of the pericardium resulting in sharp chest pain, worsened by breathing and improved by leaning forward.
- Causes include infection (viral/bacterial), autoimmune diseases, and uremia.
- Diagnosis includes pericardial friction rub, EKG changes (pan ST segment elevation), and echocardiography.
Cardiac Tamponade
- A medical emergency with fluid in the pericardial sac leading to decreased cardiac output, presenting with Beck's Triad: hypotension, jugular venous distention, and muffled heart sounds.
- Diagnosed via ultrasound or CT and treated with needle pericardiocentesis.
Risk Assessment Tools
- TIMI Risk Score identifies patients at risk for major cardiac events during unstable angina/NSTEMI or STEMI evaluations.
- HEART Score assesses risk of major cardiac events, particularly useful for non-specific pain or patients with no known heart disease history.
Initial Evaluation Process
- History of Present Illness (HPI) structured using SAMPLE (Signs, Allergies, Medications, Previous history, Last intake, Events leading up).
- Further assessed using OPQRST (Onset, Provocation, Quality, Radiation, Severity, Time).
- Comprehensive physical exam focusing on vital signs and cardiac assessment.
Laboratory Testing
- Initial labs include CBC, CMP, troponin, and chest X-ray.
- Additional tests may involve BNP (for CHF), inflammatory markers (ESR, CRP), and D-dimer if PE is suspected.
Troponin in Cardiac Injury
- Key marker for cardiac injury, with elevations indicating acute processes.
- Serial troponin tests are essential to assess cardiac strain, with interpretations ranging from normal to critical based on levels and changes over time.
Diagnosis and Disposition
- Diagnosis relies on differential evaluation and work-up results, with non-specific chest pain being the most common diagnosis.
- Decisions on admission or discharge are based on overall assessment and risk stratification.
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Description
This quiz explores the critical aspects of diagnosing and managing chest pain in the emergency department. It highlights causes of chest pain, the urgency of treatment for acute myocardial infarction, and the implications of missed diagnoses. Test your knowledge on this vital topic in emergency medicine.
