Medicine Case 1: Chest Pain

Front 1

5 broad categories of chest pain:

Back 1

Cardiac causes, gastrointestinal disorders, pulmonary disorders, musculoskeletal causes, and psychogenic causes

Front 2

Cardiac causes of chest pain differential:

Back 2

-Stable angina
-Unstable angina
-Acute MI
-Atypical or variant angina (coronary vasospasm, Prinzmetal's angina)
-Cocaine-induced chest pain
-Pericarditis
-Aortic dissection: tearing chest pain radiating to back
-Valvular heart disease, i.e., critical aortic stenosis
-Cardiac arrhythmia

Front 3

Gastrointestinal disorders causes of chest pain:

Back 3

-Esophageal disease (GERD, esophagitis, esophageal dysmotility)
-Biliary disease (cholecystitis, cholangitis): typically RUQ with radiation to shoulder, may be referred to chest
-Peptic ulcer disease
-Pancreatitis

Front 4

Pulmonary disorders causing chest pain:

Back 4

-Pneumonia
-Spontaneous pneumothorax
-Pleurisy
-Pulmonary embolism
-Pulmonary hypertension/cor pulmonale
-Pleural effusion

Front 5

Musculoskeletal causes causing chest pain:

Back 5

-Costochondritis
-Rib fracture
-Myofascial pain syndromes
-Muscular strain
-Herpes zoster

Front 6

Psychogenic causes of chest pain:

Back 6

-Panic disorders
-Hyperventilation
-Somatoform disorders

Front 7

Cardiac risk factors

Back 7

smoking, hypertension, dyslipidemia, diabetes, family history of CAD, or previously documented CAD, peripheral arterial disease, or stroke

Front 8

Ischemic vs. Non-ischemic pain

Back 8

Front 9

Atypical symptoms of a cardiac event

Back 9

dyspnea, fatigue, nausea, abdominal discomfort, or syncope

Front 10

Classic angina

Back 10

is retrosternal chest pain that comes on with exertion and is relieved with rest or nitroglycerin - stable angina describes symptoms that have been occurring chronically and are predictable with exertion.caused by a stable atherosclerotic plaque

Front 11

Unstable angina

Back 11

is when the chest pain occurs at rest, is new, is increasing in frequency, or when its onset is triggered with a lower level of exertion caused by an unstable plaque that has ruptured and caused a non-occlusive thrombus

Front 12

Diagnosis of acute MI

Back 12

the typical rise and fall of troponin or creatine kinase myocardial band (CK-MB) plus ONE of the following:

- Symptoms consistent with myocardial ischemia

- Electrocardiogram changes indicating myocardial ischemia (ST-segment elevation or depression)

- New pathologic Q waves

- Findings on percutaneous coronary intervention (PCI).

Front 13

What's the difference clinically btwn acute NSTEMI and unstable angini

Back 13

No troponin increase = No MI

Front 14

Treatments for unstable angina

Back 14

sublingual nitroglycerin, beta blockers, heparin, aspirin, statin, PCI

Front 15

The (thrombolysis in myocardial infarction)TIMI risk score includes the following items

Back 15

If present, the item is scored is +1, if absent, the score is 0.

Age ≥65 years
Presence of at least three risk factors for CHD (hypertension, diabetes, dyslipidemia, smoking, or positive family history of early MI)
Prior coronary stenosis of ≥50 percent
Presence of ST-segment deviation on admission ECG
At least two anginal episodes in prior 24 hours
Elevated serum cardiac biomarkers
Use of aspirin in prior seven days (which is probably a marker for more severe coronary disease)


Patients are considered to be at low risk with a score of 0 to 2; intermediate risk with a score of 3 to 4; and high risk with a score of 5 to 7.

Front 16

Rough ECG anatomy

Back 16

V1-V4 reflect the anterior wall; leads II, III and AVF reflect the inferior portion of the heart; and leads I, AVL, V5 and V6 correspond to the lateral myocardial wall.

Front 17

Left Bundle Branch Block diagnosis criteria:

Back 17

The criteria to diagnose a left bundle branch block on the electrocardiogram:
The heart rhythm must be supraventricular in origin.
The QRS duration must be = or > 120 ms.
There should be a QS or rS complex in lead V1.
There should be a monophasic R wave in leads I and V6.
The T wave should be deflected opposite the terminal deflection of the QRS complex

Front 18

absolute contraindications for thrombolytic therapy include:

Back 18

Strong suspicion of dissection of the aorta
Pericardial effusion
Active gastrointestinal or other internal bleeding
Brain tumor, arteriovenous malformation, or aneurysm
Ischemic stroke in preceding 6 months (a verified transient ischemic attack (TIA) is an exception)
Previous intracerebral hemorrhage or subarachnoid hemorrhage
Intracranial procedure or recent head trauma
Severe known bleeding disorder: coagulation abnormality, thrombocytopenia, etc.

Front 19

a GP IIb/IIIa inhibitor such as abciximab or eptifibatide

Back 19

inhibits platelet aggregation and may prevent platelet adhesion to the vessel wall. While these medications increase the risk of bleeding (especially when used in combination with fibrinolytics) and can cause thrombocytopenia within 24 hours of initiation, they improve outcomes in patients with STEMI.

Front 20

when do you prefer CABG vs. PCI

Back 20

CABG may be preferred in left main lesions or in complex proximal LAD disease with other unfavorable lesions (three-vessel disease) or in patients with left ventricular dysfunction or diabetes mellitus.

Front 21

acute complications of acute MI

Back 21

include arrhythmias (bradyarrhythmias and tachyarrhythmias), reduced ventricular function, cardiogenic shock, papillary muscle dysfunction with acute valvular dysfunction, ventricular free wall rupture, and recurrent thrombosis.