Chest Pain

Front 1

1. Utility of knowing risk factors for ischaemic heart disease on USMLE (2 things)?

Back 1

1. Helping answer diagnostic questions in equivocal cases.
2. Modifying them can lower mortality

Front 2

2. Criteria for significant family history of ischaemic heart disease?

Back 2

a. Family member must be young
b. Female relative <65, Male relative <55

Front 3

3. Presentation of Coronary Artery Disease?

Back 3

a. Presents w/chest pain that does not change with body position or respiration.
b. CAD is NOT associated w/chest wall tenderness

Front 4

4. Single worst or most dangerous factor for Coronary Artery Disease?

Back 4

Diabetes

Front 5

5. Risk factors for Ischaemic heart disease (CAD)?

Back 5

1. DM
2. HTN
3. Tobacco
4. Hyperlipidemia
5. Peripheral artery disease
6. Obesity
7. Inactivity
8. Family hx

Front 6

6. When any one of the following 3 features, the patient does NOT have CAD?

Back 6

1. Pleuritic chest Pain (changes w/respiration)
2. Positional chest pain
3. Tender (pain on palpation)

Front 7

7. Pleuritic pain differential?

Back 7

1. Pulmonary embolism
2. Pneumonia
3. Pleuritis
4. Pericarditis
5. Pneumothorax

Front 8

8. Positional chest pain differential?

Back 8

Pericarditis.

Front 9

9. Tender chest pain differential?

Back 9

Costochondritis.

Front 10

10. Most common cause of chest pain?

Back 10

Acid reflux.

Front 11

11. A pt comes to the ED w/chest pain. The pain also occurs in the epigastric area and is associated w/a sore throat, a bad metallic taste in the mouth, and a cough. What do you recommend?

Back 11

PPI

Front 12

12. An alcoholic pt comes to the ED w/CP. There is N/V and epigastric tenderness. What do you recommend?

Back 12

Check amylase and lipase levels.

Front 13

13. A pt comes to the ED w/CP. There is right upper quadrant tenderness and mild fever. What do you recommend?

Back 13

Order an abdominal sonogram for gallstones.

Front 14

14. Clues to ischaemic pain as the cause of chest pain are?

Back 14

a. Dull pain (“tightness,” “heaviness,” or “pressure,”)
b. Lasts 20–30 minutes or more
c. Occurs on exertion
d. Substernal location
e. Radiates to the jaw or left arm.

Front 15

15. Significance of S3 gallop?

Back 15

Dilated left ventricle

Front 16

16. Significance of S4 gallop (4)?

Back 16

a. Left ventricular hypertrophy
b. Jugular venous distention
c. Holosystolic murmur of mitral regurg

Front 17

17. Rales on physical exam?

Back 17

Suggestive of CHF

Front 18

18. Mitral regurg murmur?

Back 18

Holosystolic murmur.

Front 19

First step in management for ischemic–type pain.

Back 19

Note: An EKG is always the best initial diagnostic test for ischemic–type pain. If the case presented to you is very clearly a case of ischaemic pain and the examiners ask you to choose between and EKG and aspirin, nitrates, oxygen, and morphine, then choose treatment first.

Front 20

What will be the answer if the question asks about the most ACCURATE test for ischaemic chest pain?

Back 20

Note: When the question asks about the most ACCURATE test for ischaemic chest pain, the answer is CK–MB or troponin.

Front 21

21. CK–MB vs. troponin?

Back 21

a. Both rise at 3–6 hrs after the start of chest pain.
b. They have nearly the same specificity.
c. The main difference between CK–MB and troponin is that CK–MB stays elevated for 1–2 days while troponin stays elevated for 1–2 weeks. Therefore, CK–MB testing is the best test to detect reinfarction a few days after the initial infarction.

Patients with a normal CK-MB level but elevated troponin levels are considered to have sustained minor myocardial damage, or microinfarction, whereas patients with elevations of both CK-MB and troponins are considered to have had acute myocardial infarction.

Front 22

22. When is Myoglobin the right answer for chest pain?

Back 22

a. When the question asks “which of the following will rise first?” when the choices are all cardiac enzymes.
b. Myoglobin elevates as early as 1–4 hrs after the start of chest pain.

Front 23

When to answer “consultation” for single best answer questions?

Back 23

Note: Do not answer “consultation” for single best answer questions. However, “consultation” is ok to answer as a part of CCS management. In single best answer questions, a consultant should not be necessary when ordering an ekg, checking enzymes, and giving aspirin to a pt w/acute coronary syndrome.

Front 24

24. A 56 yo man comes to the office a few days after an episode of chest pain. This was his first episode of pain, and he has no risk factors. IN the ED, he had a normal EKG and normal CK–MB, and was released the next day. Which of the following is most appropriate in his further management?

Back 24

Stress (exercise tolerance) testing.
Stress test when the case is equivocal or uncertain for the presence of CAD. Do not do an angiography unless the stress test is abnormal. Exercise tolerance testing detects CAD when the heart rate is raised and ST segment depression is detected. This case is asking you to know that a stress test is way of increasing sensitivity of detection of CAD beyond an EKG and enzymes.

Front 25

When an exercise stress test is considered positive for myocardial ischemia?

Back 25

>2 mm ST-segment depressions or hypotension (a drop of >10 mm Hg in systolic pressure) occur
either alone or in combination.

Front 26

26. When do I answer dipyridamole or adenosine thallium stress test or dobutamine echo?

Back 26

a. Pts who cannot exercise to a target heart rate of >85% of maximum.
b. COPD
c. Amputation
d. Deconditioning
e. Weakness/Previous stroke
f. Lower–extremity ulcer
g. Dementia
h. Obesity

Front 27

27. When do I answer exercise thallium testing or stress echo?

Back 27

EKG is unreadable for ischaemia:
1. Left bundle branch block
2. Digoxin use
3. Pacemaker in Place
4. Left ventricular hypertrophy
5. Any baseline abnormality of the ST segment of the EKG.

Front 28

28. When is the Sestamibi nuclear stress testing appropriate?

Back 28

Obese pts and those w/large breasts because of the greater ability of this radioisotope to penetrate tissue.

Front 29

Other circumstances when nuclear stress test is appropriate.

Back 29

This test is also not affected by baseline changes in the ECG (LBBB, ST-segment depression at baseline, etc.).

Front 30

How to read nuclear stress test?

Back 30

An abnormal amount of thallium will be seen in those areas of the heart that have a decreased blood supply. Compared to regular stress tests, the nuclear stress tests have higher sensitivity and specificity (92% sensitivity, 95% specificity vs. 67% sensitivity, 70% specificity).

Front 31

29. A 63 yo fm is in your office for evaluation of an abnormal stress test that shows an area of reversible ischaemia. She has no risk factors for CAD. What is the most accurate diagnostic test, or what is the best next step in further management?

Back 31

Angiography.
Angiogrpahy is the next diagnostic step to evaluate an abnormal stress test that shows “reversible” ischaemia. Reversible ischaemia is the most dangerous thing that a stress test can show.
If the stress test shows “fixed” defects–that is, a defect unchanged between exercise and rest– this is a scar from a previous infarction.
Fixed defects do not need angiography.

Front 32

30. With the above situation, what is the answer only if the angiogram has already been done?

Back 32

Coronary bypass.

Front 33

31. Best initial test to evaluate valve function of ventricular wall motion?

Back 33

Echocardiography.

Front 34

32. Most accurate method to evaluate ejection fraction?

Back 34

Nuclear ventriculogram.

Front 35

33. A pt admitted 5 days ago for an MI has a new episode of chest pain. Which of the following is the most specific method of establishing the diagnosis of new infarction?

Back 35

CK–MB.
CK–MB should return to normal 2–3 days after MI.
If a reinfarction has occurred, the level will go back up again 5 days later, while the troponin level will still be up from the original infarction.

Front 36

34. Utility of angiography?

Back 36

Can detect obstructive, stenotic lesions but cannot detect myocardial necrosis.

Front 37

35. In whom should stress testing NEVER be performed?

Back 37

a. If the pt is having current chest pain.
b. Chest pain is a reason to stop the stress test.

Front 38

Major Modifiable Risk Factors of ischemic heart disease?

Back 38

1. Elevated cholesterol levels

2. Tobacco

3. Hypertension.

4. Physical inactivity and exercise

5. Obesity

6. DM

Front 39

Major Uncontrollable Risk Factors of ischemic heart disease?

Back 39

1. Age: ≥65

2. Sex: men

3. Heredity: family history of
premature disease (age <55 in male relative and <65 in female relative).

Front 40

Minor Contributing Factors of ischemic heart disease?

Back 40

1. Sex hormones: decrease of natural estrogen as women age may contribute to a higher risk of heart disease after menopause.

2. Stress