Student Handout- IPC Block 5 September 2007 Week 5 Chest Pain

STUDENTS: Please complete the following cases (#1-5) and unknown electrocardiograms (#1-6) prior to your small group sessions. Remember to approach the ECGs in a systematic approach: i.e. Rate, Rhythm (including intervals), Axis, Hypertrophy, and Ischemia/Infarction.

Case 1
History:
A 56-year-old man presents to the ER with a complaint of chest pain. He reports sudden onset of crushing pain in the middle of his chest while lifting heavy boxes into a moving van. The onset was 30 minutes ago and has not let up very much since. The pain is spreading into his neck and left arm. He is quite anxious and mildly short of breath. Pt is a non-smoker; his father has HTN and had a M.I. at age 65. The patient doesnt take any regular medications. He uses occasional Tylenol for aches and pains. He has not had his cholesterol checked.

PMH: Occasional heartburn controlled with antacids. Physical Exam: Vital signs: T = 98.9, P = 70, R = 28, BP = 100/50 Pt appears anxious, restless and diaphoretic. Neck: no JVD. Lungs: clear to auscultation Heart: normal S1 and S2 without splitting. No murmurs. Abdomen: soft, non-tender, non-distended with active bowel sounds. Extremities: no clubbing, cyanosis or edema Upon arrival and after a focused history and physical exam, you obtain blood work and an ECG (ECG Unknown #1). Questions: 1) Develop a differential diagnosis for chest pain. Myocardial Infarction Pulmonary Embolism Aortic dissection Tension Pneumothorax Esophageal rupture Myocardial Ischemia/Angina Endocarditis/Pericarditis/Myocarditis Pleuritis GERD PUD Shingles Panic Attack Cholecystitis Pancreatitis Costochondritis Pneumonia and Lung Tumors

2) What is the rate? 52 /min 3) What are the following intervals? PR = 0.24 s (1st degree AV block) QRS = 0.08 s What is the rhythm? Sinus Bradycardia 4) What is the axis? 0 to -30 (still considered normal) 5) What is the main abnormality on this EKG? Describe the anatomical position and likely artery involved in this condition. Big Q wave in V1 (Zerrer says its there, but tutor guide doesnt), ST elevation in V1-V5. Probably acute anterior infarct due to occlusion of the left anterior descending artery (aka the widow maker).

Case 2
History: This patient is a 68-year-old female brought into the ER via ambulance. Her husband reports that after walking up the stairs with groceries, she clutched her chest and had to sit down on the couch. She then became sweaty and short of breath. During transport to the ER she was placed on O2 and given sublingual nitroglycerin without relief of the pain. She complains of chest pressure and tightness across her chest. Physical exam: Vitals: T = 97.6, P = 80, R = 26, BP = 108/62 General: appears pale and worried Lungs: clear to auscultation Heart: normal S1 and S2, without splitting. No murmurs. Ext: no clubbing, cyanosis or edema You obtain an ECG immediately (ECG 2). Questions 1) What is the rate? 73 /min 2) What is the rhythm? Normal Sinus What are the following intervals? PR= 0.16 s QRS= 0.08 s 3) What is the axis? +75 4) Is there hypertrophy? She probably meets voltage criteria for LVH. They say no LVH. If R in AVL is >11mm then you have LVH. 5) Is there evidence of ischemia or infarction? Describe the abnormalities that you see. Describe the cardiac anatomical position and artery likely involved in this condition. Yes. ST Depression in I, AVL, and V2, V4, V5 ST Elevation in II, III, and AVF. They say no Q Waves in II, III, AVR because they arent at least 1 block wide. Dont use AVR for anything really. Probably an acute inferior infarct due to occlusion of the right coronary artery. Might also have some posterior infarct as well (look at depression in V2). Either distal RCA or circumflex could cause posterior infarction.

6) Review the risk factors for coronary artery disease. + Family History => Male <55, Female <65 Male gender Blood lipid abnormalities (LDL HDL mainly) Diabetes mellitus Hypertension Physical inactivity and obesity Cigarette smoking Consumption of too few fruits and vegetables and too much alcohol Renal insufficiency

Case 3
A 70 year old female presents to you for evaluation prior to her knee surgery. During your evaluation, she reports that she has occasional dyspnea on exertion and chest tightness while carrying grocery bags into her home. This doesnt affect her daily activities because the pain is relieved with a brief rest. Past medical history: Osteoarthritis of her knees. Type II diabetes mellitus. Social: Married. Quit smoking 5 years ago. Medications: NSAIDS, Glipizide Physical Exam: BP 130/70 HR 70 bpm Wt 100 kg General: Pleasant and cooperative, uses a cane to ambulate in the office Heart: Normal S1 and S2, no murmurs Lungs: Clear to auscultation What options are available for assessing for the presence of coronary artery disease in this patient and what are their advantages/disadvantages? Chemical Stress Test (dobutamine stress echo; obviously cant use the treadmill): Ischemic areas show wall motion abnormality. Hard to do in overweight people. Cant use adenosine in people with asthma. Adenosine + Nuclear Medicine: adenosine is a vasodilator. Has high sensitivity. Measures perfusion. 85-95% sensitive? Review the normal myocardial perfusion scan and the perfusion scan for this patient (Case Image 3A and B). What are your findings? Inferolateral severe reversible perfusion. Decreased perfusion in inferolateral distribution. Case 4 A 49 year old female presents for an annual check-up. She reports that she has been having some occasional substernal chest pains. She describes them as sharp and radiating to the right shoulder. They are 6/10 on a pain scale. The pain occurs both at rest and at exertion and often resolves after about five minutes of rest. She reports approximately 2 episodes per month since their onset six months ago. She is concerned that she might be having heart problems because her father had a heart attack. Past medical history: Hypothyroidism, hyperlipidemia, gastroesophageal reflux disease. Medications: Synthroid, ranitidine Social history: She is a smoker. Family history: Father had a myocardial infarction at age 60.

Examination: Vitals HR 75 bpm BP 124/68 RR 16/minute General: Mildly overweight, no acute distress. Heart: Normal S1 and S2 without murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally. Ext: no edema A baseline ECG obtained in clinic showed a normal sinus rhythm, without evidence of acute changes. Interpret the baseline electrocardiogram in this patient (Case 4 ECG Pre-Test). Rate: 58 /min Rhythm: Sinus Bradycardia Intervals PR: 0.20 s QRS: 0.08 s Axis: +0 Hypertrophy: No (maybe some left atrial enlargement) Ischemia/Infarction: noop What is your suspicion for underlying coronary artery disease in this patient? Smoking, obesity, hyperlipidemia, family history (but not really). She appears to be having angina (retrosternal crushing pain, relieved by rest, SOB, sweating, nausea). Angina 1. Substernal pressure tightness 2. Brought on by exertion 3. Relieved by rest/nitro 3 of 3: Classic angina 2 of 3: Atypical Angina => What we have probably 1 of 3: Non-anginal Unstable angina can occur during rest? They assessed her at 3% chance of significant CAD, but it could be 15-20% if she has atypical angina. Review the indications and contraindications for cardiac stress testing. Indications Evaluation of chest pain Determination of prognosis Evaluate effects of therapy Evaluation of arrhythmias (not in tutor guide) Evaluation of functional capacity Screening in high risk individuals (preop risk, high risk professions) Exercise prescription Absolute Contraindications Acute MI Unstable angina Uncontrolled arrhythmias Severe Aortic stenosis Decompensated CHF

Acute PE Acute myocarditis/pericarditis Acute aortic dissection Acutely ill patients No consent Relative Contraindications Moderate Aortic stenosis Suspected left main disease Severe hypertension (>200/110) HOCM Inability to exercise High grade AV block Tachy- or brady-arrhythmias Electrolyte abnormalities, severe anemia, hyperthyroidism What test would you proceed with and why? Cardiac Stress Test. If they have intermediate/high pretest probability you should undergo testing. In this patient, if her pretest probability is only 3% you may not want to do the test. Interpret the exercise electrocardiogram (Case 4: performed during Stage 4 of stress test). Are there signs of ischemia? No. Who can tell really? Interpret the Case 4 recovery phase ECG. Rate: 115 /min Rhythm: Sinus Tachycardia Intervals PR: 0.20 s QRS: 0.08 s Axis: +0 Hypertrophy: Left Atrial Enlargement? Nope Ischemia/Infarction: no What information does this provide to our patient? How should she be advised? Shes nuts. Stop smoking and start exercising. She has a 4 year survival probability of 99%. (Review the concepts of sensitivity, specificity, positive predictive value, and negative predictive value.) Case 5 A 70 yr old man presents for pre-operative evaluation for cataract surgery. He maintains an active lifestyle and denies any past medical problems. He hasnt been to a doctor in years. No prior surgeries. On ROS, he reports mild substernal chest tightness during the last year. He notices it most when he is climbing stairs and it usually resolves with 10 minutes of rest. He has mild associated dyspnea. No radiation of the pain. Past Medical History: Denies history of DM, HTN, cancer. Social: Smokes 1 pack per day. Retired factory worker. Family History: Parents deceased. Father had diabetes. Medications: None Examination: Vitals HR 67 bpm BP 160/92

General: Thin, well appearing male Heart: Normal S1 and S2 without murmur. Lungs: Clear to auscultation Skin: Xanthelasma (cholesterol deposits) of the upper eyelids You are concerned about underlying coronary artery disease in this patient. What factors are important to consider in selecting a stress test for a patient? Smokes 1 ppd. Family history of diabetes. Hasnt been to the doctor in years. Chest pain upon exertion. Mild Dyspnea too. He has classical angina (3 of 3). Probably chronic stable angina. Pre test probability is 94%. Interpret the pre-test electrocardiogram (Case 5: Resting ECG). Rate: 60 /min Rhythm: Normal Sinus Intervals: PR=0.12 QRS=0.08 Axis: +60 Hypertrophy: Borderline LVH by voltage (but limb leads are on torso so cant really look at LVH in pretest EKG) and Left Atrial Enlargement Ischemia/Infarction: He has some small Q waves in II, III, AVF, and V4-V6. Otherwise looks okay. Interpret the Case 5 exercise electrocardiogram. (Note: This ECG was performed during early recovery phase to minimize interference from exercise.) Are there signs of ischemia? Rate: 150 /min Rhythm: Sinus Tachycardia Intervals: PR=0.16 QRS=0.08 Axis: +90 Hypertrophy: Borderline LVH and Left Atrial Enlargement Ischemia/Infarction: ST Depression in V4-V6. Cant predict location in exercise stress test. Significant ST Depression: 3 beats in row, greater than 1 box depressed, greater than 2 boxes wide. Horizontal or sloping downward. What is the next step in this patients evaluation? Cardiac cath. Additional Example of Exercise Stress Test: Interpret ECG A: StressTestRestingECG. Rate: 68 /min Rhythm: Normal Sinus Intervals: PR = 0.20 s QRS = 0.08 s Axis: +60 Hypertrophy: Cant evaluate since limb leads on torso. BBB: no Ischemia/Infarction: Non specific ST changes in V5-V6. Inverted T waves in III and AVF (not significant though)

Interpret ECG B: StressTestECGStageII, with associated chest discomfort. Rate: 100 /min Rhythm: Normal Sinus Intervals: PR = 0.20 s QRS = 0.08 Axis: +120 Hypertrophy: Possible left atrial enlargement BBB: no Ischemia/Infarction: Marked ST Depression in II, III, AVF, V3-V6. Interpret ECG C: StressTestECG5minsRecovery. What is the significance of this series of ECGs? Rate: 63 /min Rhythm: Normal Sinus Intervals: PR = 0.16 s QRS = 0.08 Axis: +60 Hypertrophy: Possible left atrial enlargement BBB: RBBB (no!) Ischemia/Infarction: Inverted Ts and ST depression in II, III, and AVF? Suggests presence of severe coronary disease => underwent CABG.

Unknown Electrocardiograms for Week 5: Chest Pain

Unknown 1 29 year old with chest pain Rate: 60 /min Rhythm: Normal Sinus Intervals: PR = 0.16 s QRS = 0.08 s Axis: +0 to +15 Hypertrophy: no BBB: no Ischemia/Infarction: Inverted Ts in III. V2-V3 = early repolarization (not pathologic) Unknown 2 52 year old with nausea and chest pain Rate: 45 /min Rhythm: Sinus Bradycardia Intervals: PR = 0.20 s QRS = 0.08 s Axis: +0-90 (tutor guide says it is +45) Hypertrophy: no BBB: no Ischemia/Infarction: ST Elevation in II, III, and AVF. Reciprocal ST Depression in V2 (An isolated Q in III is not significant) Acute inferior infarct

Unknown 3 55 year old with chest pain Rate: 60 /min Rhythm: Normal Sinus Intervals: PR = 0.20 s QRS = 0.08 s Axis: +0 Hypertrophy: no BBB: no Ischemia/Infarction: Deep Symmetric Inverted Ts in all of the chest leads indicating ischemia. Lack of R wave progression. Small inferior Qs in III and AVF. Anterior infarct, indeterminate age Unknown 4 77 year old with not feeling well Rate: 58 /min Rhythm: Sinus Bradycardia Intervals: PR = 0.20 s QRS = 0.12 s Axis: +30 Hypertrophy: no BBB: LBBB (look at V6 and width of QRS) Ischemia/Infarction: Inverted Ts in I, II, III, AVF, and AVL. Cant really see b/c of LBBB. Unknown 5 54 year old with chest pain Rate: 54 /min Rhythm: Sinus Bradycardia Intervals: PR = 0.20 s QRS = 0.08 s Axis: +30 Hypertrophy: no BBB: no Ischemia/Infarction: Q wave in III (isolated so we dont care). Non-specific ST-T abnormalities. Unknown 6 Parts A in ED with chest pain for 2 hours Part B serial ECG 2 days later Rate: 64 /min Rhythm: Normal Sinus Intervals: PR = 0.20 s QRS = 0.10 s Axis: +30 Hypertrophy: no BBB: no Ischemia/Infarction: ST elevation in V2-V6. Acute Anterolateral Infarct (NO Q WAVES HERE!) Rate: 90 /min Rhythm: Sinus Rhythm Intervals: PR = 0.16 s QRS = 0.08 s Axis: -180 Hypertrophy: no BBB: no Ischemia/Infarction: ST Elevation in V2-V4, Q wave in I, Q waves in V1-V4.