Risk Factors and Chest PainRisk Factors and Chest Pain

• Risk factors can increase likelihood of chest Risk factors can increase likelihood of chest pain being cardiacpain being cardiac– Regardless of the character (i.e. atypical MI)Regardless of the character (i.e. atypical MI)

• But the But the charactercharacter of chest pain (MI or not?) of chest pain (MI or not?) carries the most weight in the initial workupcarries the most weight in the initial workup

Chest Pain: More likely cardiacChest Pain: More likely cardiac

• 65 year old man 65 year old man – with intermittent CP, no past medical historywith intermittent CP, no past medical history

• initial (most likely) dx? initial (most likely) dx? – ischemic heart diseaseischemic heart disease

• initial test? EKG, later a CXRinitial test? EKG, later a CXR– after stablized/vitalsafter stablized/vitals– r/o worst case, noninvasiver/o worst case, noninvasive

Chest Pain: Less likely cardiacChest Pain: Less likely cardiac

• 45 year old woman 45 year old woman – with intermittent CP, no past medical historywith intermittent CP, no past medical history

• initial (most likely) dx? initial (most likely) dx? – GERDGERD

• initial test? EKG, later a CXR initial test? EKG, later a CXR – r/o worst case, noninvasiver/o worst case, noninvasive

Risk Factors for CADRisk Factors for CAD

• Mnemonic: “CHOSED A Boy Friend”Mnemonic: “CHOSED A Boy Friend”• CholesterolCholesterol• HTNHTN• ObesityObesity• SmokingSmoking• ExerciseExercise• DiabetesDiabetes• AgeAge• BoyBoy• Family historyFamily history

Risk Factors: CholesterolRisk Factors: Cholesterol

• High LDL—most importantHigh LDL—most important• Low HDL—importantLow HDL—important• TRG—less importantTRG—less important

– Less certain to be involved in dzLess certain to be involved in dz

Risk factors: Most commonRisk factors: Most common

• HTNHTN: : most common risk factormost common risk factor– meds, regardless of #’smeds, regardless of #’s– Systolic = diastolic for riskSystolic = diastolic for risk– 5X> than DM5X> than DM

• DM is a IHD equivalentDM is a IHD equivalent– Treatment implicationsTreatment implications

““Most common cause of…”?Most common cause of…”?

• these questions are about epidemiology and these questions are about epidemiology and statisticsstatistics– answer is usually the most common dzanswer is usually the most common dz

• hemoptysis? hemoptysis? – bronchitis, not TB/CAbronchitis, not TB/CA

• a-fib? a-fib? – HTN, not pheo/hypothyroidism/PE/MSHTN, not pheo/hypothyroidism/PE/MS

Risk factors: DependentRisk factors: Dependent

• ObesityObesity• ExerciseExercise

– addresses addresses metabolic synmetabolic syn

Risk factors: MortalityRisk factors: Mortality

• correcting all of these reduce mortalitycorrecting all of these reduce mortality• smokingsmoking: :

– most effective in reducing mortalitymost effective in reducing mortality– 10+cigarettes daily10+cigarettes daily

Risk Factors: Age and FamilyRisk Factors: Age and Family

• AgeAge– 45 male45 male– 55 female55 female

• BoyBoy– but if over 45, don’t count gender against himbut if over 45, don’t count gender against him

• FHx: sudden death from MIFHx: sudden death from MI– 55 male55 male– 65 female 165 female 1stst degree relative degree relative

Chest pain: r/i most likelyChest pain: r/i most likely

• determines next step in managementdetermines next step in management– regardless of risk factorsregardless of risk factors

• chest pain from MIchest pain from MI– nonpalpational, nonpleuritic, nonpositionalnonpalpational, nonpleuritic, nonpositional– in real lifein real life 4% of the time can be any of above 4% of the time can be any of above

Chest pain: r/o most deadlyChest pain: r/o most deadly

• What is ACS?What is ACS?– Plaque rupture Plaque rupture superimposed thrombus superimposed thrombus

coronary occlusioncoronary occlusionACSACS

• Get an EKG to r/o MI!Get an EKG to r/o MI!• most common cause of death in men (USA)most common cause of death in men (USA)• and and woman (USA)woman (USA)

– # of woman MI mortalities > # of deaths from # of woman MI mortalities > # of deaths from next 4 most common causes of deathnext 4 most common causes of death

Chest Pain: w/nonspecific signsChest Pain: w/nonspecific signs

• Fever, SOBFever, SOB– Present in Present in allall etiologies of chest pain etiologies of chest pain

• DyspneaDyspnea– Indicates severe hypoxiaIndicates severe hypoxia– Not in MI unless Not in MI unless CHF CHF– Pneumothorax, PEPneumothorax, PE

Chest pain: pleuriticChest pain: pleuritic

• all start with a “P” and most are pulmonaryall start with a “P” and most are pulmonary• inflammatory/infectiousinflammatory/infectious

– pleuritis/pericarditispleuritis/pericarditis– pneumoniapneumonia

• clot/bleedclot/bleed– PE/DVTPE/DVT– PostpartumPostpartum– PneumothoraxPneumothorax

Chest pain: positionalChest pain: positional

• PericarditisPericarditis– changes with leaningchanges with leaning

• better leaning forwardbetter leaning forward• worse leaning backworse leaning back

– pleuriticpleuritic

Chest pain: palpationalChest pain: palpational

• costochondritis costochondritis chest wall tenderness chest wall tenderness

Stress TestStress Test

• Goal: Maximal heart rateGoal: Maximal heart rate• Needs to be able to exerciseNeeds to be able to exercise• Needs to have a readable EKGNeeds to have a readable EKG

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