Risk Factors and Chest Pain :Risk Factors and Chest Pain Risk factors can increase likelihood of chest pain being cardiac Regardless of the character (i.e. atypical MI) But the character of chest pain (MI or not?) carries the most weight in the initial workup


Chest Pain: More likely cardiac :Chest Pain: More likely cardiac 65 year old man with intermittent CP, no past medical history initial (most likely) dx? ischemic heart disease initial test? EKG, later a CXR after stablized/vitals r/o worst case, noninvasive


Chest Pain: Less likely cardiac :Chest Pain: Less likely cardiac 45 year old woman with intermittent CP, no past medical history initial (most likely) dx? GERD initial test? EKG, later a CXR r/o worst case, noninvasive


Risk Factors for CAD :Risk Factors for CAD Mnemonic: “CHOSED A Boy Friend” Cholesterol HTN Obesity Smoking Exercise Diabetes Age Boy Family history


Risk Factors: Cholesterol :Risk Factors: Cholesterol High LDL—most important Low HDL—important TRG—less important Less certain to be involved in dz


Risk factors: Most common :Risk factors: Most common HTN: most common risk factor meds, regardless of #’s Systolic = diastolic for risk 5X> than DM DM is a IHD equivalent Treatment implications


“Most common cause of…”? :“Most common cause of…”? these questions are about epidemiology and statistics answer is usually the most common dz hemoptysis? bronchitis, not TB/CA a-fib? HTN, not pheo/hypothyroidism/PE/MS


Risk factors: Dependent :Risk factors: Dependent Obesity Exercise addresses metabolic syn


Risk factors: Mortality :Risk factors: Mortality correcting all of these reduce mortality smoking: most effective in reducing mortality 10+cigarettes daily


Risk Factors: Age and Family :Risk Factors: Age and Family Age 45 male 55 female Boy but if over 45, don’t count gender against him FHx: sudden death from MI 55 male 65 female 1st degree relative


Chest pain: r/i most likely :Chest pain: r/i most likely determines next step in management regardless of risk factors chest pain from MI nonpalpational, nonpleuritic, nonpositional in real life 4% of the time can be any of above


Chest pain: r/o most deadly :Chest pain: r/o most deadly What is ACS? Plaque rupture ? superimposed thrombus? coronary occlusion?ACS Get an EKG to r/o MI! most common cause of death in men (USA) and woman (USA) # of woman MI mortalities > # of deaths from next 4 most common causes of death


Chest Pain: w/nonspecific signs :Chest Pain: w/nonspecific signs Fever, SOB Present in all etiologies of chest pain Dyspnea Indicates severe hypoxia Not in MI unless ? CHF Pneumothorax, PE


Chest pain: pleuritic :Chest pain: pleuritic all start with a “P” and most are pulmonary inflammatory/infectious pleuritis/pericarditis pneumonia clot/bleed PE/DVT Postpartum Pneumothorax


Chest pain: positional :Chest pain: positional Pericarditis changes with leaning better leaning forward worse leaning back pleuritic


Chest pain: palpational :Chest pain: palpational costochondritis ? chest wall tenderness


Stress Test :Stress Test Goal: Maximal heart rate Needs to be able to exercise Needs to have a readable EKG


Chest Pain: initial workup :Chest Pain: initial workup 45 year old woman exertional, intermittent CP with no PMHx shows up to your office without any CP Best initial test? EKG done for all CP to r/o MI NL EKG: next step? Active CP ? + EKG ? enzymes Nonactive, cardiac CP ? stress test Nonactive, noncardiac-type CP ? GI evaluation