approach to chest pain, palpitations, lower extremity pain and edema Terms in this set (99) The initial pivotal points in the evaluation of chest pain are the (3) duration of symptoms, the patient’s vital signs, and ECG . Acute: Subacute: Chronic : Acut

approach to chest pain, palpitations, lower extremity pain and edema Terms in this set (99) The initial pivotal points in the evaluation of chest pain are the (3) duration of symptoms, the patient’s vital signs, and ECG . Acute: Subacute: Chronic : Acute < 2 weeks Subacute: < 3 months Chronic : > 6 months what constitutes a chest pain emergency? Acute CP and/or unstable vital signs and/or abnormal ECG first 2 steps of a approaching a pt with acute chest pain Step 1 (even before/while obtaining history) = ECG, VS Step 2 = Characterize the CP, focus on "do not miss diagnoses" = AAS (acute aortic syndrome), ACS, PE Acute Coronary Syndrome (ACS) Myocardial infarction, Unstable Angina Acute Aortic Syndrome (AAS) disorders of the thoracic and abdominal aorta that are usually symptomatic and require urgent evaluation and consideration for surgical intervention (aortic dissection) Pulmonary Embolism (PE) blood clot in pulmonary arteries. Angina + diff types Discomfort in the chest and/or adjacent areas ( jaw, shoulder, back, arm), usually, but not always, due to myocardial ischemia. Typical vs atypical angina Stable vs unstable angina Noncardiac Chest Pain = Chest pain that meets only 1 or none of the typical angina characteristics. Typical Angina Substernal chest discomfort PLUS all of the following: Characteristic oppressive quality Provoked by exertion or emotional stress. Relieved by rest or nitroglycerin Atypical Angina Substernal chest discomfort PLUS 2 typical features. More common in women approach to chest pain, palpitations, lower extremity pain and edema Stable (chronic coronary syndromes) angina Chronic and recurring episodes without any change in symptom pattern Unstable Angina presenting as rest angina, severe new-onset angina, or acceleration of previously diagnosed effort angina. what questions do we always ask to identify ischemic sxs of a pt with chest pain? (5) What does the CP feel like? Oppressive, substernal discomfort is classic for angina Do you have it when you get up and exert yourself? Does it go away with rest? Do you notice it traveling anywhere else? Radiation to L/R, jaw or both arms/shoulders is concerning for cardiac etiology Are you sweaty with it? Do you feel nauseous? Dizzy? These associated symptoms are concerning for cardiac etiology Typical angina that is prolonged or occurs at rest unstable angina Atypical angina that is prolonged or occurs at rest with high probability of CAD, what to ask next? look at risk factors such as Diabetes Smoking Hypertension Hyperlipidemia Family history of premature CAD Postmenopausal status Peripheral vascular disease Cocaine use (sympathetic system toxicity) The following features suggest causes other than angina/cardiac etiology (4) very brief pain lasting less than 15 seconds dull, localized (< 3 cm) pain, especially in the inframammary region localized, superficial chest pain reproduced by palpation radiation to the upper jaw or below the umbilicus once you rule out ACS/MI with ECG of a pt with acute chest pain, what are the other "do no miss" dxs to look for? PE and acute aortic syndrome classic sxs of acute aortic syndrome (aortic dissection) Sudden onset severe "tearing" or "ripping" pain Severe persistent pain radiating to the back Severe migrating chest and back pain classic signs of acute aortic syndrome (aortic dissection) Hypertension Pulse discrepancy in the extremities. (diminished or unequal) A diastolic murmur may develop due to dissection in the ascending aorta close to the aortic valve, causing valvular regurgitation classic sxs of PE sudden onset of shortness of breath and severe chest pain that increases with inspiration ("pleuritic chest pain"). + / - hemoptysis Associated unilateral leg swelling approach to chest pain, palpitations, lower extremity pain and edema classic signs of PE HR > 100 O2 sat < 95% risk factors of PE Recent surgery or trauma Exogenous hormone use Hx of thrombophilia (blood forms clots easily) what are some sxs that are specific to PE? hemoptysis and and pleural rub why is it hard to dx PE? patients present in a variety of ways and signs and symptoms are neither sensitive nor specific. after ruling out MI, PE, and AAS, what are other do not miss diagnoses with acute chest pain? -acute chest syndrome from sickle cell crisis -pericarditis -myocarditis -infective endocarditis Acute Chest Syndrome is defined as a new infiltrate on chest radiograph in association with one other new sign or symptom Acute chest syndrome is the leading cause of death in patients with HbSS in the United States acute chest syndrome: signs and sxs fever >38.5°C (101.3°F), cough, wheezing, tachypnea (fast heart rate), or chest pains. Myocarditis inflammation of the heart muscle myocarditis typically hx and signs/sxs often follows an URI + CP, + signs/symptoms of HF (Dyspnea on exertion, edema) pericarditis inflammation of the sac surrounding the heart typical presentation of pericarditis Anterior pleuritic chest pain that is worse supine (laying flat), improved upright, leaning forward. usually followed by URI physical exam of pericarditis Pericardial friction rub, +/- fever infective endocarditis inflammation of endothelium that lines heart and cardiac valves. typical hx of pt with infective endocarditis fever, days to weeks Nonspecific symptoms: cough; dyspnea; arthralgias or arthritis; diarrhea; and abdominal, back, or flank pain. a lot of systemic sxs bc embolized bacteria Symptoms may occur as a result of embolization, metastatic infection or immunologically mediated phenomena IV drug use is common precipitator physical exam of pt with infective endocarditis Petechiae (palate, conjunctiva) Splinter hemorrhages Osler nodes (painful, violaceous raise lesion of the fingers, toes or feet) ---ouchie Janeway lesions (painless erythematous lesions of the palms or roles) Roth spots (exudative lesions in the retina) Tricuspid regurgitation murmur Osler nodes painful, violaceous raise lesion of the fingers, toes or feet) approach to chest pain, palpitations, lower extremity pain and edema Janeway lesions painless erythematous lesions of the palms or soles) seen in infective endocarditis Roth spots exudative lesions in the retina seen in infective endocarditis what tool to use if a pt comes in with acute chest pain with some risk factors but from ur clinical reasoning, "do not misses" are ruled out? use heart score to determine what further testing you may need (i.e, monitoring, stress test, more troponins, echo, etc) MACE Major adverse cardiac events Heart Score The HEART Pathway developed by Mahler et al (2015) combined the HEART Score with 0- and 3-hour cardiac troponin tests in a decision aid designed to identify ED patients safe for early discharge. No MACE were seen within 30 days in patients who were identified for early discharge. H=history E=ekg A=age R=risk factors T=troponin Heart scores 0-3 0.9-1.7% risk of adverse cardiac event. In the HEART Score study, these patients were discharged heart scores 4-6 2-16.6% risk of adverse cardiac event. In the HEART Score study, these patients were admitted to the hospital. heart scores >/7 50-65% risk of adverse cardiac event. In the HEART Score study, these patients were candidates for early invasive measures. when to not use heart score if new ST-segment elevation requiring immediate intervention or clinically unstable patients. other causes of chest pain: skin system herpes zoster cp with paresthsia, on one side, pain with light touch other causes of chest pain: MSK system Costochondritis Tietze syndrome Pectoral muscle strain Rib fracture Cervical or thoracic spondylosis (C4-T6) Myositis other causes of chest pain: esophageal Spasm Rupture GERD Esophagitis Neoplasm other causes of chest pain: GI PUD Gallbladder disease approach to chest pain, palpitations, lower extremity pain and edema other causes of chest pain: pulmonary Pleural effusion Pneumonia Neoplasm Viral infections Pneumothorax Neoplasm Pulmonary embolism other causes of chest pain: psychogenic dx of exclusion Anxiety Depression Somatoform Secondary gain typical hx of palpitations History is key, as palpitations are often intermittent, and not experienced during a medical evaluation focus of pt interview with palpitations The focus of the interview is to identify patients who require diagnostic testing for serious arrhythmia (beyond an ECG). what do we do with pts who have palpitations with syncope/near syncope? work up for arrhythmia (holter, cardiac event monitor, ref to cardio) 3 other cases in which a pt with palpitations is getting a arrhythmia workup -has underlying heart disease -palpitations last longer than 5 min -any ekg changes what to try and rule out before u think palpitations care caused by arrhythmia? anemia and thyroid disease what to always ask a pt with palpitations to identify alarm features (6) Does it happen during or after exercise? Have you ever passed out during an episode? Do you have a history of heart disease (coronary artery disease, congenital or valvular heart disease, hypertrophic cardiomyopathy, or dilated cardiomyopathy)? Do you have a family history of sudden cardiac death or known arrhythmia? What medications are you on? Do you use any drugs recreationally (stimulants - cocaine, meth, amphetamines, caffeine; tobacco and EtOH)? what diagnostic test do we always get for a pt with palpitations? ecg!! Medications that can prolong the QT interval or cause arrhythmias Antiarrhythmics Methadone Antipsychotics Antiemetics Diuretics (by way of electrolyte abnormalities) important FH with palpitations A family history of sudden cardiac death or known arrhythmia raises concern for idiopathic VTach palpitations while standing and feeling AVNRT approach to chest pain, palpitations, lower extremity pain and edema palpitations during exercise extreme fear is concerning for VTach from long QT syndrome palpitations after exercise is concerning for SVT (Afib) due to increased vagal tone Syncope or presyncope symptoms with palpitations is concerning for VTach or SVT that is sufficiently rapid to reduce effective cardiac output this is not normal and should always be evaluated 3 caveats to keep in mind when evaluating arrhythmias 1. While history is important, no single element can distinguish between arrhythmic and nonarrhythmic causes 2. Many arrhythmias are asymptomatic and may not correlated with symptoms reported during ambulatory ECG 3. Providers tend to underdiagnose arrhythmias in patients with psychiatric disorders and palpitations. 3 types of etilogies for approaching atraumatic leg pain -venous, systemic, and arterial venous etiologies of atraumatic leg pain WILL have edema Deep venous thrombus (DVT) Chronic venous insufficiency systemic etiologies of atraumatic leg pain WILL have edema Heart failure Kidney failure Liver failure arterial etiologies of atraumatic leg pain WILL NOT have edema Peripheral artery disease Acute arterial occlusion 2 causes of peripheral venous disease 1. venous thromboembolism (VTE. deep or superficial) 2. venous insuffiency peripheral venous disease: venous thromboembolism (VTE) (VTE, deep or superficial) Thrombus (clot) is in periphery and blocks blood flow back to heart peripheral venous disease: venous insuffiency Chronic venous engorgement from venous occlusion or incompetent venous valves; blood can't get back to heart and pools in legs. often bilateral!! signs and sxs of dvt Laterality of Edema Pain Pulses Temperature Skin Changes Ulceration Unilateral Constant pain Normal pulse Warm +/- erythema No ulceration what kinds of risk factors should you ask pt abt when evaluating for DVT? Recent injury/immobilization? Exogenous estrogen use? Active malignancy? Central venous catheter? approach to chest pain, palpitations, lower extremity pain and edema signs and sxs of chronic venous insufficiency Laterality of Edema Pain Pulses Temperature Skin Changes Ulceration Bilateral Improved with elevation Normal pulse Normal temp Brown pigmentation around ankle, stasis dermatitis, thickening of the skin and narrowing of the legs If ulcer forms, going to be at medial aspect of ankle Peripheral Arterial Disease stenotic, occlusive, and aneurysmal disease of the abdominal aorta, its mesenteric and renal branches, and the arteries of the lower extremities, exclusive of the coronary arteries. what can PAD lead to? atherosclerosis Can lead to complete obstruction at the site (thrombus) or complete obstruction can come from other site (clot travels from heart to mesenteric arteries for example) why is it important to ID pad in adults? triple risk for MI and stroke risk factors of PAD Tobacco use? HTN? DM? Dyslipidemia? CAD ? History of dysrhythmias (like A-fib) why is it hard to dx PAD? the narrowing of artery has to be pretty severe for pts to have sxs need a good hx blockage of PAD is typically to where their sxs are proximal Signs and Symptoms of PAD -leg pain but NO swelling -pain with exertion; relieved by rest within ten mins (intermittent claudication) -foot pale on elevation, dusky red when lowered -dec pulse/absent -lose hair on legs -ulceration -gangrene Acute Limb Ischemia An Emergency! If the pain is constant, the narrowing is likely critical; if it is excruciating, a major artery has probably been severely compromised acutely. acute limb ischemia presentation 5 Ps of ischemia Pain Pulselessness Paresthesias, paralysis Pallor Poikilothermia volume backing up into systemic circulation approach to chest pain, palpitations, lower extremity pain and edema left sided HF volume backing up into pulmonary circulation reduced EF HF and most common cause mpaired emptying (CAD --> hypokinesis of ventricle --> dilated, floppy, weak --> can't eject all blood out) preserved EF HF and most common cause impaired filling (uncontrolled HTN --> LVH --> thickening impairs filling) what info to gather when taking a history of a pt with suspected HF Assess risk factors for HF HTN, CAD, EtOH, illicit drug use classic sxs of HF Fatigue-most common sxs but not specific Dyspnea on exertion Orthopnea: shortness of breath when lying down Paroxysmal nocturnal dyspnea: feeling of breathlessness that occur with lying down. Edema general R sided vs L sided HF sxs R sided is more edema L sided is more lung type sxs R sided HF sxs leg edema and abdominal distension, which is due to venous pooling. Loss of appetite caused by intestinal edema L sided HF sxs Shortness of breath Orthopnea Paroxysmal nocturnal dyspnea A chronic nonproductive cough is a nonspecific finding but is often present. Fatigue, which is due to reduced cardiac output. Exercise intolerance results from pulmonary venous congestion, which causes dyspnea. R sided HF signs Jugular venous distention due to elevated right-sided pressures Ascites-fluid in belly Hepatic enlargement Pitting edema Parasternal heave Positive hepatojugular reflex L sided HF signs crackles or rales on pulmonary examination Murmurs which may indicate aortic stenosis or mitral regurgitation S3 S4 two signs that are very very specific for HF s3 (have pt lay on L side and use bell) jugular venous distention