Nursing

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South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Internal Medicine

Internal Medicine 02: 60- year-old woman with chest pain

Author:Author: Kirk A. Bronander, MD; Associate Editor, Amy E. Blatt, MD; Case Editor, Amalia Landa-Galindez, MD

INTRODUCTION CARE DISCUSSION

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

MENUMENU

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Dr. Lorenzen asks Dr. Lorenzen asks you to see Ms. Johnston.you to see Ms. Johnston.

!

You are working with Dr. Lorenzen, who asks you to start interviewing Susan Johnston, a patient she knows well who is here to discuss recent symptoms of chest pain.

DIFFERENTIAL DIAGNOSIS CLINICAL REASONING Before seeing the patient, Dr. Lorenzen asks you to review the differential diagnosis for chest pain. She reminds you, “There are many causes of chest pain including cardiac, gastrointestinal, pulmonary, musculoskeletal and psychogenic causes.”

Question List below three potential causes of chest pain in each of the categories mentioned.

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The suggested answer is shown below.

Pericarditis, Myocardial Infarction, Aortic Dissection, GERD, Esophageal Spasm, Heart Burn, Pneumonia, Pleuritis, Flu, Costochondritis, Trauma, Lower Rib Pain Syndrome, Anxiety, Hyperventilation, Depression.

Letter Count: 207/1000

SUBMITSUBMIT

Answer Comment See Teaching Point below

Broad DiIerential Diagnosis of Chest Pain

CardiacCardiac

Cardiovascular Causes of Chest PainCardiovascular Causes of Chest Pain

SymptomsSymptoms SignsSigns OtherOther abnormalitiesabnormalities

AnginaAngina

Chest pressure that may radiate to neck/arm/shoulder. May have associated

May have abnormal blood pressure, lower

May have ST segment

TEACHING POINTTEACHING POINT

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Pectoris/CoronaryPectoris/Coronary Artery DiseaseArtery Disease

dyspnea. Risk factors include obesity, diabetes, hypertension and hyperlipidemia.

extremity edema, cardiac murmurs or normal exam.

abnormalities on EKG.

Variant AnginaVariant Angina

Vasospastic cause of angina, often younger pt with few risk factors. Risk factors include tobacco use.

Between episodes of chest pain physical exam may be completely normal.

Accompanied by transient ST elevation on EKG.

Cocaine InducedCocaine Induced Chest PainChest Pain

Chest pain after cocaine use from infarction or intense coronary spasm.

Patients may have burn marks on lips and fingers from crack pipe, needle marks on skin from injections, and/or inflammation and ulcerations in the pharynx and nasal septa.

Urine tox screen positive for cocaine and drug metabolites. Elevated CPK levels may be seen with associated rhabdomyolysis.

Aortic DissectionAortic Dissection

Crushing or tearing quality pain in center of chest, radiates to back.

Murmur of aortic insufficiency may be present.

Widened mediastinum on CXR.

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Valvular HeartValvular Heart DiseaseDisease

Aortic stenosis can result in anginal pain. Mitral prolapse patients often have atypical chest pain.

AS – systolic crescendo decrescendo murmur, MVP – midsystolic click with possible late systolic murmur.

PericarditisPericarditis

Severe retrosternal, often pleuritic, pain that varies with body positioning.

Pericardial friction rub.

Diffuse ST elevation and PR depressions on EKG, pericardial effusion on echocardiogram.

Non-ischemicNon-ischemic CardiomyopathyCardiomyopathy

Usually does not manifest as chest pain but rather dyspnea or other CHF symptoms.

Pulmonary edema, hepatic congestion, lower ext edema, jugular venous distension.

Enlarged heart on CXR, elevated b- type naturetic peptide.

CardiacCardiac Syndrome XSyndrome X

Exertional angina- like chest pain, more common in women.

Usually normal EKG, abnormal exercise stress test with normal coronaries on angiogram and no evidence of coronary spasm.

Similar to

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MyocarditisMyocarditis pericarditis but can also mimic ischemia.

May manifest as CHF.

Cardiac enzymes may be elevated.

GastrointestinalGastrointestinal

Gastrointestinal Causes of Chest PainGastrointestinal Causes of Chest Pain

SymptomsSymptoms SignsSigns Other AbnormalitiesOther Abnormalities

EsophagealEsophageal DiseaseDisease

Reflux associated chest pain usually occurs after meals, is exacerbated by lying down or bending over, and improved by antacids. May be associated with chronic cough.

May be associated with laryngitis or posterior oropharyngeal erythema in severe cases.

BiliaryBiliary

Usually presents with right upper quadrant or epigastric pain. Pain may be

Murphy’s sign – tender palpable gallbladder with a sudden halt of Abnormal liver function

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DiseaseDisease exacerbated by fatty foods and may be accompanied by nausea and/or vomiting.

inspiration with palpation in the upper quadrant. Occasional jaundice

tests

PepticPeptic UlcerUlcer DiseaseDisease

Gnawing, midepigastric pain.

Epigastric tenderness

Ulceration/inflammation seen on endoscopy

PancreatitisPancreatitis

Moderate to severe midepigastric pain with radiation to the back. May be accompanied by nausea and vomiting.

Epigastric tenderness

Elevated amylase and lipase

PulmonaryPulmonary

Pulmonary Causes of Chest PainPulmonary Causes of Chest Pain

SymptomsSymptoms SignsSigns OtherOther AbnormalitiesAbnormalities

PneumoniaPneumonia Productive cough, fever

Crackles on lung exam, egophony, whispered pectoriloquy

Infiltrate on CXR, elevated WBC

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SpontaneousSpontaneous PneumothoraxPneumothorax

Acute pleuritic chest pain and dyspnea

Decreased breath sounds and resonance to percussion in affected hemithorax, possible tachycardia, distended neck veins, and hypotension

Abnormal CXR

PleurisyPleurisy

Pleuritic chest pain, dyspnea, possible viral syndrome

Pleural friction rub heard with lung auscultation, small tidal volume breathing

Possible pleural effusion on CXR

PulmonaryPulmonary EmbolismEmbolism

Pleuritic chest pain associated with dyspnea

Tachycardia, hypoxemia, possible right heart strain on EKG

Abnormal CT angiography of chest, V/Q scan, elevated D-dimer

MusculoskeletalMusculoskeletal

Musculoskeletal Causes of Chest PainMusculoskeletal Causes of Chest Pain

SymptomsSymptoms SignsSigns OtherOther AbnormalitiesAbnormalities

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CostochondritisCostochondritis

Sharp anterior chest pain occurring at costochondral and costosternal junctions.

Tenderness to palpation over chest wall.

Rib FractureRib Fracture

Pleuritic chest pain, worsened by movement, often associated trauma

Tender over affected rib

Rib fractures seen on X-ray

Myofascial PainMyofascial Pain SyndromesSyndromes

Widespread pain often with trigger points, often associated depression or sleep disorder

Tender to palpation over trigger points

Muscular StrainMuscular Strain

Chest pain after excessive exercise or cough

Possible chest wall tenderness

Pain and possible

Rash absent initially then characteristic vesicular rash that

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Herpes ZosterHerpes Zoster itching in a dermatomal pattern

follows dermatomal distribution, not crossing midline.

PsychogenicPsychogenic

Psychogenic Causes of Chest PainPsychogenic Causes of Chest Pain

SymptomsSymptoms SignsSigns OtherOther AbnormalitiesAbnormalities

Panic DisorderPanic Disorder

Sudden intense anxiety often associated with palpitations, dyspnea

Tachycardia, tachypnea, diaphoresis, and/or tremor

HyperventilationHyperventilation

Dyspnea, light- headedness, often associated with anxiety

Tachypnea ABG shows low PCO2

SomatoformSomatoform DisordersDisorders

Variety of somatic complaints, can include chest pain. Often history of

Subjective complaints outnumber objective findings

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psychiatric illness

CHART REVIEW AND HISTORY TAKING HISTORY

You begin your interview of Ms. Johnston.You begin your interview of Ms. Johnston.

!

You proceed to the patient’s room and review the chart before going into the room.

You learn that Susan Johnston is a 60 year-old female with a history of hypertension and dyslipidemia. On today’s chart the medical assistant has indicated that Ms. Johnson is having episodes of chest discomfort, and has recorded the vitals:

” DEEP DIVEDEEP DIVE

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Vital signs:Vital signs:

Temperature:Temperature: 98.6 Fahrenheit Heart rate:Heart rate: 82 beats/minute Respiratory rate:Respiratory rate: 14 breaths/minute Oxygen saturation:Oxygen saturation: 94% on room air Blood pressure:Blood pressure: 138/78 mmHg Weight:Weight: 220 pounds Height:Height: 5’ 6”

You enter Ms. Johnston’s room and introduce yourself. Ms. Johnston asks that you call her “Susan.”

“I’ve reviewed your chart, Susan, but I’d like to hear you describe why you wanted to be seen by the doctor today?” “I have been having a strange sensation in my chest for the past 3 months and I decided it was time I should have the doctor look into it.”

“Can you describe this discomfort you’ve experienced?” “Yes. It is right in the middle of my chest and it feels like burning at times and sometimes a tingling sensation. It always goes away, but it is starting to concern me.”

“When do you get these pains?” “Sometimes the pain occurs when I am active, like climbing stairs, but other times it can occur when I am just sitting watching TV.”

“Have you passed out or felt dizzy?” She denies any episodes of feeling dizzy or passing out. “No, none of that.”

With further questioning you discover that at its worst it was a 6 out of 10 in

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severity. She feels short of breath when the sensation occurs but does not have diaphoresis, nausea, vomiting, dyspepsia or belching, or palpitations. There is no change in the pain with changes in body positioning. The discomfort does not radiate to her neck, jaw or arm. She has never been awakened from sleep with the sensation. The discomfort is not occurring more frequently and is not changing in its severity.

MEDICATIONS AND HISTORY HISTORY Susan tells you she has never had any kind of heart problem, and has never been told she has a heart murmur. She has a history of high blood pressure, and Dr. Lorenzen had also recommended she take a medication for elevated cholesterol but she has not started the cholesterol medication. When you ask why, she states, “I don’t like taking pills.”

Medications:Medications:

Lisinopril 20 mg daily

Hydrochlorothiazide 25 mg daily

She occasionally takes an aspirin but not every day, as it gives her dyspepsia.

Review of Systems:Review of Systems: Unremarkable except she has slowly gained weight over the last 15 years.

Social HistorySocial History: Susan has never smoked. She drinks alcohol rarely, does not use recreational drugs and is monogamous in a married relationship for many years. She has two grown children and works as a secretary. She does not exercise on a regular basis. Dietary history was not detailed but she did admit to eating “quite a bit of fast food.”

Family HistoryFamily History: Her father died of a heart attack at age 57. Mother is alive and in relatively good health. One sister has “adult-type diabetes.”

PHYSICAL EXAM PHYSICAL EXAM

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You listen to Ms. Johnston’s heart.You listen to Ms. Johnston’s heart.

!

You present the information you have obtained so far to Dr. Lorenzen, then she suggests you both return to the room for Susan’s physical examination.

The findings from the physical examination are:

Vital signs:Vital signs:

Temperature:Temperature: 98.6 Fahrenheit Heart rate:Heart rate: 82 beats/minute Respiratory rate:Respiratory rate: 14 breaths/minute Body Mass Index:Body Mass Index: 35.5 kg/m Blood pressure:Blood pressure: 136/82 mmHg Weight:Weight: 220 lbs Height:Height: 5’ 6”

2

Head, eyes, ears, nose and throat (HEENT):Head, eyes, ears, nose and throat (HEENT): No abnormalities.

Neck:Neck: No thyromegaly, jugular venous distension or carotid bruits.

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Heart:Heart: The cardiac point of maximal impulse (PMI) is not palpable. There is no tenderness to palpation of the chest wall. Auscultation reveals a normal S1 and S2 with no murmurs, rubs or gallops.

Lungs:Lungs: Normal lung excursion with normal lung sounds.

Abdomen:Abdomen: Obese, soft and nontender. There is no hepatomegaly or splenomegaly.

Extremities:Extremities: No edema.

Vascular:Vascular: Pulses in radial, carotid, and dorsalis pedis arteries are brisk, symmetric and 2+ bilaterally.

SUMMARY STATEMENT CLINICAL REASONING

Question Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.

Guidel ines for summary statements.Guidel ines for summary statements. Your response is recorded in your student case report.

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Patient is a 60 Years old women with Hx of HTN, high cholesterol presenting to the ER with intermittent chest pain lasting for 1 week that appears on exertion and sometimes at rest, physical exam unremarkable, V/S WNL, currently taking Lisinopril 20 MG and HTZ 25 MG, family Hx of heart disease and DM. Denies tobacco, drug or alcohol use.

Letter Count: 339/1000

SUBMITSUBMIT

Answer Comment Susan Johnston is a 60-year-old female with a past history of obesity, hypertension and dyslipidemia and a family history of cardiac disease who presents with a three month history of intermittent burning anterior chest pain associated with SOB, that seems to occur with exertion and improve with rest. Other than hypertension and her elevated BMI, her physical exam is within normal limits.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

1. Epidemiology and risk factors: 60-year-old female with history of obesity, hypertension and dyslipidemia and family history of cardiac disease. 2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

burning chest pain three months of intermittent symptoms association with SOB

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The best options are indicated below. Your selections are indicated by the shaded boxes.

occurs with exertion and improves with rest physical exam unremarkable other than hypertension

The 2017 ACC/AHA Hypertensive Guidelines recommend a blood pressure of less than 120/80. For more information about managing hypertension, see the Aquifer Hypertension Guidelines module.

NARROWING THE DIFFERENTIAL DIAGNOSES

CLINICAL REASONING

Question Which of the following are the top twotwo diagnoses on your differential at this point?

A. Aortic dissection (AD)

B. Angina

C. Pulmonary embolus (PE)

D. Gastroesophageal reflux disease (GERD)

E. Myocardial infarction (MI)

F. Musculoskeletal pain

G. Pleurisy

H. Pneumothorax

SUBMITSUBMIT

Answer Comment

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> The correct answers are B, D> The correct answers are B, D

Angina, (B)(B), is an important diagnosis to consider because the patient has risk factors including an elevated BMI, a family history of coronary artery disease, hypertension and hyperlipidemia, and her symptoms are often associated with exertion and shortness of breath.

GERD, (D)(D), is in the differential because the pain is described as a burning midsternal pain. Additionally, the patient’s body habitus with elevated BMI may put her at higher risk for reflux.

DiIerential of Intermittent Exertional Chest Pain and Shortness of Breath Most Likely / Most Important DiagnosesMost Likely / Most Important Diagnoses

AnginaAngina

Some patients report pain from angina as ‘burning,’ although it is not the classic descriptor. Since women often report atypicalwomen often report atypical symptomssymptoms, angina is a reasonable diagnostic consideration in a woman with atypical symptoms prompted by exertion. In some patients shortness of breathshortness of breath is the only symptom of cardiac ischemia. This is called an “anginal equivalent.”

GERDGERD Associated chest pain is often described as “burning””burning” Not usually associated with exertion

Less Likely DiagnosesLess Likely Diagnoses

Aortic

Usually occurs acutely and presents with sudden onset of crushing,sudden onset of crushing, severe chest pain which radiatessevere chest pain which radiates

TEACHING POINTTEACHING POINT

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dissection to the backto the back. It is not episodic.

Myocardial infarction

Can cause chest painchest pain and shortnessshortness of breathof breath AcuteAcute presentation

Pulmonary embolism

AcuteAcute onset, not episodic Chest pain is often pleuriticpleuritic in nature and associated with shortness of shortness of breathbreath

Musculoskeletal pain

Usually associated with a history of injury or overexertion Pain often worse with position change and there is usually focal chest wall tenderness

Pleurisy or pneumothorax

Cause unilateral pleuritic chestunilateral pleuritic chest painpain

CHARACTERIZING ANGINAL CHEST PAIN TEACHING Dr. Lorenzen asks for your assessment of Susan’s chest pain. You tell her that at this point you feel angina is a possible diagnosis. From your reading on angina, you know that you should try to characterize the patient’s symptoms as typical angina vs. atypical angina.

Susan has a burning sensation in her chest associated with dyspnea which occurs with exertion and usually resolves with rest. While the reliable onset with exertion and usual improvement with rest are consistent with typical angina, the burning and tingling quality of her chest pain and lack of radiation are not typical features of angina. You think her symptoms would be

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considered atypical angina. Dr. Lorenzen agrees with you.

Because Susan’s discomfort has been present for three months, seems to follow a relatively predictable pattern, and has not worsened in severity, frequency, or occurred at rest, her chest pain, if angina, would be characterized as stable angina.

Characterizing Chest Pain and Angina The Three Criteria for Typical AnginaThe Three Criteria for Typical Angina

1. Substernal chest discomfort with a characteristic duration and features 2. Provoked by exertion or emotional stress 3. Relief with rest or nitroglycerin

Atypical Angina and Noncardiac Chest PainAtypical Angina and Noncardiac Chest Pain

Atypical angina is defined as chest pain having 2 of the 3 features of typical angina noted above. Patients who have diabetes, females, and older adults > 65 years of age are more likely to present with atypical features. Occasionally they will present with only weakness or shortness of breath on exertion. Those symptoms are considered “anginal equivalents”. Noncardiac chest pain is defined as meeting 1 or none of the characteristic anginal features noted above.

Stable vs. Unstable AnginaStable vs. Unstable Angina

Angina occurs when myocardial oxygen demand exceeds supply. When angina is thought to be present it is important to further characterize it as stable angina vs. unstable angina since these two syndromes are managed very differently.

Stable angina pectoris is a predictable pattern of chest discomfort that usually occurs with exertion or extreme emotion. It is relieved by rest or nitroglycerin in less than 5-10 minutes.

Unstable angina is a more serious condition characterized by chest pain that occurs at rest or with increasingly less exertion. New onset angina

TEACHING POINTTEACHING POINT

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The best options are indicated below. Your selections are indicated by the shaded boxes.

(within 4-6 weeks) and angina that has worsening severity, frequency or duration is also classified as unstable. Unstable angina is an acute coronary syndrome (along with non-ST segment elevation myocardial infarction and ST segment elevation myocardial infarction) and requires emergency care.

RISK FACTORS FOR CORONARY ARTERY DISEASE

TEACHING

Question Of the following, which are risk factors for coronary artery disease? Select all that apply.

A. Age > 55 in females

B. Male sex

C. Family history of sudden death or premature CAD

D. Smoking

E. Dyslipidemia

F. Diabetes mellitus

G. Moderate alcohol use

H. Excessive caffeine use

I. Hypertension

J. Obesity

K. Mitral valve prolapse

SUBMITSUBMIT

Answer Comment

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Answer Comment > The correct answers are A, B, C, D, E, F, I, J> The correct answers are A, B, C, D, E, F, I, J

Many risk factors have been independently associated with coronary artery disease. Nonmodifiable risk factors include older age, defined as > 45 years in males and > 55 years in females (A)(A), male sex (B)(B), and family history of premature coronary artery disease (C)(C).

There are several modifiable risk factors for the development of CAD, including cigarette smoking (D)(D), dyslipidemia (E)(E), diabetes mellitus (F)(F), hypertension (I)(I), and obesity (J)(J). Many of these risk factors are associated with each other. For example, individuals with diabetes often have other risk factors such as hyperlipidemia and hypertension.

Alcohol consumption in moderate quantities (G), defined as one alcoholic beverage per day for females and two per day in males, may be beneficial in decreasing the risk of atherosclerotic cardiovascular disease, but is generally not recommended in the United States due concern for alcohol dependence. Higher volume comsumption is associated with detrimental health effects, including liver disease and direct myocardial injury.

Caffeine consumption (H) and mitral valve prolapse (K) have not been shown to increase the risk for coronary artery disease.

Risk Factors for Coronary Artery Disease and Atherosclerotic Cardiovascular Disease Many risk factors have been independently associated with coronary artery disease. In addition to age > 55 in females or > 45 in males, male sex, family history of sudden death or premature CAD, smoking, dyslipidemia, diabetes mellitus, hypertension, and obesity; other risk factors for coronary artery disease are a sedentary lifestyle, a personal history of peripheral vascular or cerebrovascular disease, estrogen use and chronic inflammation.

TEACHING POINTTEACHING POINT

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Most of a person’s risk for CVD and for stroke (together called atherosclerotic cardiovascular disease, or ASCVD) can be determined by a limited set of major risk factors. Of those listed above, only age, male sex, current smoking, dyslipidemia, diabetes, and hypertension are considered major traditional risk factors. Other minor risk factors are only helpful if they adjust a patient’s risk category from that determined by the major risk factors.

American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend assessing major ASCVD risk factors every 4 to 6 years in adults 20 to 79 years of age who are free from ASCVD.

For more required information about risk factors for ASCVD, read the Aquifer Cholesterol Guidelines Module.

PRIMARY AND SECONDARY PREVENTION

MANAGEMENT

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Dr. Lorenzen asks you what test you should perform.Dr. Lorenzen asks you what test you should perform.

!

Prevention of Cardiovascular Disease Primary preventionPrimary prevention of cardiovascular disease (preventing disease in those without known disease) involves avoiding tobacco, aggressively controlling diabetes mellitus, keeping blood pressure and cholesterol in the normal range, and regular exercise. The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. For adults aged 60-69 years of age with a 10% or greater 10 year risk of CVD, the decision to use low dose aspirin for primary prevention must be individualized based on each patient’s life expectancy and longterm bleeding risk. For patients < 50 years or > 70 years, there is insufficient evidence to assess the balance of risks versus benefits of daily aspirin use for primary prevention.

Secondary preventionSecondary prevention (preventing further disease in those with known

TEACHING POINTTEACHING POINT

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disease) involves avoidance of risk factors, more aggressive cholesterol lowering, and optimizing hypertension and diabetic control. Aspirin and statins are mainstays of secondary prevention for most patients. Certain cardiovascular medications such as beta-blockers and angiotensin converting enzyme (ACE) inhibitors may be used as well, particularly for patients who have suffered a myocardial infarction and/or have reduced ventricular systolic function.

Question What is the best diagnostic test you could next perform in most clinic settings for a patient like Susan? What information can it provide?

The suggested answer is shown below.

Echocardiogram. It can show the perfusion of the heart and the blood vessels.

Letter Count: 78/1000

SUBMITSUBMIT

Answer Comment Electrocardiogram (ECG)

Electrocardiogram, or ECG, is a noninvasive and fairly inexpensive test that can readily be used in outpatient as well as inpatient settings,

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which can detect changes of acute myocardial ischemia or prior cardiac damage. This can be followed up by more extensive testing such as radionuclide stress testing.

Electrocardiogram With an electrocardiogramelectrocardiogram, you can rule out an ST elevation MI, look for evidence of prior infarction (pathologic Q waves) and, occasionally, make other diagnoses such as pericarditis.

INTERPRETING THE ECG TESTING

Susan’s ECGSusan’s ECG

!

TEACHING POINTTEACHING POINT

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Question What is your interpretation of Susan’s ECG?

The suggested answer is shown below.

Normal EKG.

Letter Count: 11/1000

SUBMITSUBMIT

Answer Comment Thank you for your response!

This electrocardiogram reveals sinus rhythm with a normal axis of electrical activity and has normal PR and QRS intervals. There are flat T waves in lead III and inverted T’s in V1. These are nonspecific changes and may be normal for the patient. It would be helpful to have a previous ECG to compare.

ORDERING APPROPRIATE LABS TESTING Dr. Lorenzen continues to explain, “Because our differential includes atypical

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The best options are indicated below. Your selections are indicated by the shaded boxes.

angina, we need to get some further testing to help us make the diagnosis.”

When ordering tests, it is always important first to consider how the outcome of that test will impact your diagnosis and/or treatment plan. As you respond to the following questions, please consider how each test would help you.

Question Which of the following lab tests would you order? Select all that apply.

A. CBC

B. Basic Metabolic Panel

C. TSH

D. Fasting lipid panel

E. Cortisol level

SUBMITSUBMIT

Answer Comment > The correct answers are A, B, C, D> The correct answers are A, B, C, D

A CBC (A)(A), basic metabolic panel (B)(B), TSH (C)(C), and fasting lipid panel (D)(D) would all be appropriate studies to obtain as part of the diagnostic evaluation of a patient with suspected angina.

Please refer to the Teaching Point below for the rationale for ordering each of these studies.

A cortisol level (E) would be important in the evaluation of suspected adrenal insufficiency. Since Susan has no symptoms to suggest this diagnosis and adrenal insufficiency is not a typical cause of angina, a cortisol level should not be obtained in the evaluation of suspected angina.

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Evaluation of Suspected Angina In addition to an ECG, there are several laboratory test that may be useful in the evaluation of patient with suspected angina.

Obtaining a CBC is important to evaluate for a low hemoglobin. This is important because anemia reduces oxygen capacity which can aggravate or trigger ischemia and subsequent anginal symptoms, particularly when hemoglobin levels drop below 8 g/dL.

The basic metabolic panel provides valuable information, including evidence of renal disease, hyperglycemia, and electrolyte imbalances that can lead to cardiac disease. Knowing a patient’s baseline BUN, creatinine, and electrolyte values may also be helpful when determining which cardiac medication are safest to prescribe since some medications can alter electrolytes and renal function.

Assessment of thyroid function with a TSH level may be valuable in evaluating potential triggers for angina. Hyperactivity of the thyroid can be associated with increased oxygen demands on the heart, while diminished thyroid function may aggravate risk factors such as weight gain and dyslipidemia.

Assessment of accurate fasting lipid values is particularly important in the workup on angina, as hyperlipidemia is a modifiable and independent risk factor for coronary artery disease.

While not directly related in the pathophysiology of coronary artery disease, assessment of baseline transaminase levels is important when initiation of statin therapy is being considered.

IMAGING STUDIES FOR CHEST PAIN TESTING

TEACHING POINTTEACHING POINT

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The best option is indicated below. Your selections are indicated by the shaded boxes.

Question Which radiologic tests would you order at this time? Choose the single best answer.

A. Chest x-ray

B. Chest CT

C. RUQ ultrasound

SUBMITSUBMIT

Answer Comment > The correct answer is A> The correct answer is A

A chest x-ray (A)(A) will help evaluate for non-cardiac causes of chest pain and may provide clues suggestive of underlying cardiac disease.

A chest CT (B) is not a first-line imaging test in a patient like Susan with high suspicion for angina.

A RUQ Ultrasound (C) would not be an appropriate imaging study for Susan since she has no symptoms to suggest a gallbladder or biliary source for her chest pain. An ultrasound might be warranted if Susan had described colicky right upper quadrant pain, nausea, and/or vomiting associated with eating, or if her exam had revealed RUQ tenderness or a positive Murphy’s sign.

Imaging Workup for Suspected Angina A chest x-raychest x-ray is a noninvasive and a relatively inexpensive first- line imaging test for evaluating a patient with suspected anginal chest pain. It will screen for some non-cardiac causes of chest pain

TEACHING POINTTEACHING POINT

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and may suggest underlying cardiac disease. It may provide important information regarding heart size, lung fields, and bony thorax pathology.

A chest CT is not a first-line test in the workup of probable angina. If a patient’s describes chest pain that is acute in onset, pleuritic in quality, or associated with persistent dyspnea or a ripping sensation radiating to the back, then the suspicion for pulmonary embolism or aortic dissection would be high enough to warrant a chest CT angiogram as first line imaging.

COUNSELING MS. JOHNSTON CARE DISCUSSION

You discuss your concerns and recommended testing with Susan.You discuss your concerns and recommended testing with Susan.

!

You return to the patient’s room.

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“Susan, we are concerned about your symptoms. Even though the ECG is normal, we think it’s possible that your chest pain is coming from your heart. We think the blood vessels that go to your heart might be narrowed in spots, resulting in your heart not getting enough blood flow.”

You explain that you’d like to get laboratory tests to check for anemia, electrolyte problems, elevated cholesterol and thyroid conditions that might cause or contribute to her symptoms as well as a chest x-ray to see if her heart is abnormally enlarged. You also tell her that if the results of those tests are OK, you will likely want her to have a stress test.

“Susan, we can get the lab tests and x-ray as you leave the office today. I would encourage you start taking a daily aspirin because we’ve learned it is an effective preventative measure in patients older than 55, in whom we worry about heart disease. With no history of a bleeding disorder and the short time frame until we can determine the cause of the chest pain, the aspirin should be safe. And one important thing — you should try to avoid the activities that cause your chest pain, like walking up stairs. If you experience any pain that is worse than what you’ve had or doesn’t resolve quickly, you should call for an ambulance to take you to the Emergency Department.” Susan indicates she understands your instructions, and thanks you for explaining things to her.

LAB AND IMAGING RESULTS TESTING

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You look up Susan ​’s test results.You look up Susan ​’s test results.

!

Later that day, you obtain Susan Johnston’s lab work and chest x-ray reports through the practice’s electronic health record and review the results with Dr. Lorenzen.

CBC:CBC: Normal

BMP:BMP: Conventional: SI:

Na+ 136 mEq/L 136 mmol/L

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Potassium 3.6 mEq/L 3.6 mmol/L

Chloride 105 mEq/L 105 mmol/L

Bicarbonate 23 mEq/L 23 mmol/L

BUN 15 mg/dL 5.4 mmol/L

Cr 0.7 mg/dL 62 mmol/L

Fasting glucose 99 mg/dL 5.5 mmol/L

TSH:TSH: Normal

ALTALT:Normal

Fasting Lipids:Fasting Lipids: Conventional: SI:

Total Cholesterol 253 mg/dL 6.55 mmol/L

HDL 45 mg/dL 1.17 mmol/L

LDL 162 mg/dL 4.19 mmol/L

Triglycerides 250 mg/dL 2.26 mmol/L

CXR:CXR: Normal

See the associated reference ranges in conventional and SI units.

Question What are the abnormalities in the lipid panel? Select all that apply.

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A. Elevated Total Cholesterol

B. Elevated HDL

C. Elevated LDL

D. Elevated Triglycerides

SUBMITSUBMIT

Answer Comment > The correct answers are A, C, D> The correct answers are A, C, D

Susan’s total cholesterol (A)(A) and triglyceride (D)(D) levels are both elevated above the maximum recommended levels of 200 mg/dL for each.

Normal low-density lipoprotein (LDL) cholesterols have classically been defined as levels less than or equal to 130 mg/dL, but recent guidelines released by the ACC/AHA in 2018 recommend more personalized LDL targets. Based on these guidelines, a LDL level of > 160mg/dL is considered a risk enhancer for ASCVD and must be considered in conjunction with the patient’s estimated 10-year ASCVD risk to determine if targeted therapy is indicated. For patients with known ASCVD, these guidelines recommend a goal LDL < 70 mg/dL for those at very high risk of recurrent events and a goal LDL < 100 mg/dL for those with lower risk of recurrent events. While stable angina/ASCVD has not yet been confirmed for Susan, her LDL (C)(C) of > 160mg/dL would still be considered an elevated level.

Susan’s HDL (B) level of 45mg/dL is low for a female, in whom the target value is 50mg/dL or higher.

Susan may have clinical ASCVD as stable angina is high on the differential. Since her diagnosis has not yet been confirmed, you decide to estimate her 10-year ASCVD risk using Pooled Cohort Equations risk calculator, and find it is 7.2%. According to the 2018 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, this is considered an

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elevated 10-year ASCVD risk, and moderate intensity statin therapy should be discussed with Susan for primary prevention. If it is confirmed that Susan indeed has clinical ASCVD, then high-intensity statin therapy should be initiated.

Use of Fasting Lipid Levels to Further Assess ASCVD Risk and Determine Appropriate Cholesterol Treatment Plan The 2018 ACC/AHA Guidelines on Assessment of Cardiovascular Risk indicate that it is reasonable to use Pooled Cohort Equations that require lipid data to estimate 10-year ASCVD risk every 4 to 6 years in adults 40 to 79 years of age without clinical ASCVD.

Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

To learn more about cholesterol management, see the required Aquifer Cholesterol Guidelines Module.

Therapeutic lifestyle changes (TLC) should always be undertaken with or without concomitant drug treatments. These lifestyle changes include a diet with saturated fat <7% of calories, cholesterol intake <200 mg/day and increased soluble fiber intake. Exercise and weight control are also a part of lifestyle change.

References Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S76-99. DOI: 10.1161/01.cir.0000437740.48606.d1.

TEACHING POINTTEACHING POINT

” DEEP DIVEDEEP DIVE

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Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2935-59. DOI: 10.1016/j.jacc.2013.11.005.

Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 Nov. In press. DOI: 10.1016/j.jacc.2018.11.003.

Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;129(25 suppl 2):S1–S45. doi:10.1161/01.cir.0000437738.63853.7a.

CRITERIA FOR METABOLIC SYNDROME TESTING Dr. Lorenzen reviews Susan’s lab results with you and says, “Let’s go over the criteria for the Metabolic Syndrome. Susan Johnston has at least three of the risk factors — elevated triglycerides, a lower HDL cholesterol level, high blood pressure, and probably an increased waist circumference — and therefore meets the definition of Metabolic Syndrome.”

See the associated reference ranges in conventional and SI units.

Metabolic Syndrome Criteria The Metabolic Syndrome is a constellation of risk factors for cardiovascular disease that often occur in the same individual. Together they increase the risk of cardiovascular disease for any given LDL level. Metabolic syndrome has several definitions according to various subspecialty groups; however, all definitions are more alike than they are different. The Adult Treatment Panel III of the National Cholesterol Education Program defines the syndrome as three or more of the following:

Lab Values: Conventional: SI:

TEACHING POINTTEACHING POINT

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Abdominal obesity

Waist circumference (men >102 cm (40 in), women >89 cm (35 in)

Triglycerides > 150 mg/dL 1.70 mmol/L

HDL cholesterol

men < 40 mg/dL, women < 50 mg/dL

men <1.04 mmol/L, women <1.30 mmol/L

Blood pressure

> 130/85 mmHg

Fasting glucose

> 110 mg/dL >6.1 mmol/L

STRESS TEST INDICATIONS AND OPTIONS TESTING Now that you have additional information on Susan, stable angina continues to be high in the differential diagnosis. Dr. Lorenzen encourages you to consider what you believe Susan’s pre-test probability of coronary disease is before thinking about stress testing. She states that thinking about the probability of disease before ordering a test helps guide testing.

After reviewing the guidelines, you believe that based on her atypical presentation and her risk factors, Susan has an intermediate probability of coronary disease — hence, a stress test is a Class I indication.

Stress Testing Indications When Is Stress Testing Indicated?When Is Stress Testing Indicated?

The American College of Cardiology and American Heart Association’s 1997 Guidelines for Exercise Testing include a table that can be used to assess pre-test probability of coronary artery disease (Table 2) based on age,

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