3.

05 Approach to Edema, Chest Pain, & Palpitations MEDICINE I

MARIEL BAGO-AZARES, MD | November 28, 2019 LE 3 TRANS 5

OUTLINE NEED-TO-KNOW :
● Table 1a and Table 2a (see appendix). Go through this table in
I. Chest Pain C. Diagnosis
Harrison’s because in the exam, some of the questions will be
II. Myocardial Ischemia/Injury IV. Palpitations
based here. Take note of the onset/duration of the symptoms,
A. Angina C. Causes
quality of the symptoms, location, and the associated features.
III. Approach to Chest D. Approach to Palpitation
Discomfort V. Edema
A. High Risk Conditions C. Approach to Edema
II. MYOCARDIAL ISCHEMIA/INJURY
B. History and Physical D. Distribution of Edema
Examination E. Other Causes of Edema ● First to be considered when patients with chest pain come in the
ER
LEGEND
● Angina pectoris
Important Lecturer Book/Article Previous Trans ○ Myocardial ischemia causing chest discomfort
(Author) (Year & Section)
● Clinical characteristics of angina are highly similar for stable
ischemic heart disease, unstable angina, or myocardial
Lecture Objectives ischemia/injury
At the end of the lecture, the student should be able to: ○ The only difference is seen in the pattern and duration of the
1. Develop an organized process on how to approach the symptoms
symptoms of chest pain, palpitation, and edema A. ANGINA
2. Develop and formulate a diagnosis for the symptoms presented
based on the history and physical examination ● Described as sense of “strangling and anxiety”
● Chest discomfort of myocardial ischemia/injury is typically aching,
I. CHEST PAIN heavy, squeezing, crushing, or constricting
● Most common reason why patients present to the ER ○ Typical descriptions
○ 3rd most common reason for ER consults in the USA ● Minority of the patients describe it as a very vague discomfort, mild
● Broad variety of possible causes tightness, uncomfortable feeling or sense of doom
● Site of discomfort: retrosternal
○ Radiation is common and generally down to the ulnar surface
of the left arm, right arm, both arms, neck or shoulders
Stable Angina
● Ischemic episodes precipitated by exertion (such as walking or
climbing a flight of stairs), and relieved upon resting or taking
nitroglycerin
● Begins gradually and reaches its maximal intensity over a period
of minutes before resolving within several minutes with rest or
nitroglycerin
● Gradual type of pain

Figure 1. Distribution of final discharge diagnoses in patients with Unstable Angina

nontraumatic acute chest pain. ● Angina occurs with progressively lower intensity of physical activity
● Interpretation of the pie chart: (e.g. taking one step or sitting down) or even at rest
○ Most of the final discharge diagnosis for chest pain is ● Accelerating type of chest pain
gastrointestinal disorders (42%) ○ More severe than what the patient experienced before
○ Ischemic heart disease is only around 31% ● Cardiac biomarkers such as troponin are normal
○ Less than 10% is due to a life-threatening cardiopulmonary ● ECG can be unremarkable
conditions such as pulmonary embolism (PE) or aortic
Myocardial Ischemia/Injury
dissection
● More severe chest discomfort, prolonged (lasting > 30 minutes)
3 Categories of Chest Pain ● Not relieved by rest
1. Myocardial ischemia ● Unstable angina vs. Myocardial Ischemia
2. Other cardiopulmonary causes ○ MI: (+) troponin or CK MB levels
○ Pericardial disease (pericarditis )
○ Aortic emergencies (aortic dissection ) CONCEPT CHECKPOINT:
○ Pulmonary conditions (e.g. pulmonary hypertension, pneumonia ● T/F: The onset/duration of myocardial infarction is usually > 30
) minutes.
3. Non-cardiopulmonary causes ● What are the three categories of chest pain?
○ Examples: ● Chest pain that occurs at a lower intensity of physical activity,
■ Gastrointestinal problems, psychiatric disorder, and is described to be accelerating.
muskuloskeletal ● T/F: Most common discharge diagnosis for chest pain is
ischemic heart disease.
● Condition which is often associated with tearing, ripping, or
Typical Clinical Features of Acute Chest Discomfort knifelike characteristic of pain

Trans Amante, Ang-Og, Aquino, I., Aquino, L., Core Asuncion, Carreon, A.
Grps Bravante, Briones, Cresencio Cabal (0945 406 9358) 1 of 18
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3.05 Approach to Edema, Chest Pain, & Palpitations LE 3 TRANS 5

● Described as unilateral, often localized, pleuritic chest pain with B. HISTORY

associated dyspnea, cough, fever, and rales. ● Evaluation of non traumatic chest discomfort relies heavily on
Answers: clinical history and physical exam to direct subsequent
● T diagnostic testing
● (1) Myocardial ischemia, (2) other cardiopulmonary causes, (3) ● First, assess if it is a life threatening condition. If it is not a life
non-cardiopulmonary causes threatening condition based on your history and PE, then is it a
● Unstable angina chronic condition? If it is, then you have to evaluate and treat
● F. Gastrointestinal disorders (42%). Ischemic heart disease before it could lead to serious condition (e.g. stable angina, aortic
accounts for only 31%
stenosis, pulmonary hypertension).Iif not chronic, could it be due to
● Acute aortic syndrome (aortic dissection). Refer to table 1
(appendix) acute conditions (i.e. pericarditis) that warrant for treatment.
● Pneumonia or pleuritis. Refer to table 1 (appendix) Lastly, is it a treatable condition?
● Avoid just ordering troponin tests without looking into the history of
III. APPROACH TO CHEST DISCOMFORT the patient. Sometimes it’s not warranted, and it can be costly for
certain patients
● Priorities of the initial clinical encounter include assessment of the
● History
following:
○ Quality of pain
○ Patient’s clinical stability
○ Location of Pain (including radiation)
○ The probability that the patient has an underlying cause that
○ Pattern of the pain (onset and duration)
may be life-threatening
○ Provoking or alleviating factors
● Firstly, rule out life-threatening or high risk conditions
Quality of the pain
A. HIGH RISK CONDITIONS
● Quality of chest discomfort alone is never sufficient to establish a
● Cardiopulmonary
diagnosis
○ Acute coronary syndrome (ACS)
○ Even it the patient claims that it (chest discomfort) that it is a
■ Unstable Angina
heavy sensation, that is not enough to say that you might be
■ NSTEMI
dealing with myocardial ischemia.
■ STEMI
● The characteristic of the pain are pivotal in formulating an initial
○ Acute aortic syndrome
clinical impression and assessing the likelihood of serious
■ Aortic dissection
cardiopulmonary process in particular Acute coronary syndrome
○ Pulmonary embolism (PE)
(ACS)
○ Tension pneumothorax
● Severity of pain: poor diagnostic accuracy (Harrison’s)
○ Pericarditis with tamponade
■ Asking about the similarity of discomfort to previous definite
● Non-cardiopulmonary
ischemic symptoms is helpful
○ Esophageal rupture
● Unusual for angina to be sharp, as in knifelike, stabbing, or
■ Holds the greatest urgency for diagnosis (Harrison’s)
pleuritic (Harrison’s)
■ May deteriorate rapidly despite initially appearing well
(Harrisons) ● “Sharp”
○ Sometimes used to convey the intensity of discomfort rather
than the quality (Harrison’s)
Table 1. Considerations in the assessment of the patient with chest
discomfort (Harrison’s) Table 2. History taking of chest discomfort: Quality of Pain

Considerations in the Assessment of a Patient with Chest Likely MI Less Likely MI

Discomfort ● Pressure or tightness ● Pleuritic discomfort
1. Could the chest discomfort be due to an acute, ○ Typical of myocardial ○ When patients move it is
potentially life-threatening condition that warrants ischemic pain painful
urgent evaluation and management? ● Some patients with ○ Process involving pleura,
ischemic chest symptoms pericarditis, PE or
Unstable
Aortic Pulmonary deny any “PAIN” but pulmonary process
ischemic heart Pneumothorax
dissection embolism complain of dyspnea or ● “Tearing” “ripping”
disease
vague sense of anxiety ○ Acute aortic dissection
2. If not, could the discomfort be due to a chronic
■ It is a very severe pain.
condition likely to lead to serious complications?
It’s like something is
Pulmonary
Stable angina Aortic stenosis sliding down their back
hypertension
and ripping them.
3. If not, could the discomfort be due to an acute condition ● Burning quality
that warrants specific treatment? ○ Acid reflux or peptic ulcer
Pneumonia/ disease
Pericarditis Herpes zoster
pleuritis ○ Not always a GI disorder
4. If not,cold the discomfort be due to another treatable since it can also be
chronic condition? present in some cases of
Esophageal reflux Cervical disk disease myocardial ischemia
Esophageal spasm Arthritis of the shoulder or spine
● Pericarditis or massive pulmonary embolism
Peptic ulcer disease Costochondritis
○ Steady severe pressure or aching making it difficult to
Gallbladder disease Other musculoskeletal disorders
Other GI conditions Anxiety state discriminate from myocardial ischemia (Harrison’s)
● Esophageal pain with spasm
○ Severe squeezing discomfort identical to angina (Harrison’s)

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Location of discomfort sequelae (heart failure or

hypotension) (PPT Notes)
Table 3. History taking of chest discomfort: Location of Discomfort
Likely MI Less likely MI Provoking and Alleviating Factors
● Substernal location with ● Highly localized
Table 5. History taking of chest discomfort: Provoking and Alleviating
radiation to neck, jaw, ○ If the patient is able to Factors
shoulders or arms typical point to the area of the Likely MI Less Likely MI
of MI. pain, less likely that you ● Chest pain usually starts ● Alterations in intensity of
○ Retrosternal substernal might be dealing with MI. with exertion pain with changes in position
location if you’re thinking ● Prefer to rest, sit or stop or movement of the upper
MI ● Retrosternal location walking extremities or neck
● Radiation to both arms ○ Esophageal pain ● Be aware of “Warm up ○ Musculoskeletal origin
○ High association with MI ● Pain solely above the angina”: relief from angina (e.g: cervical disk
as etiology mandible or below the as they continue at the same disease)
epigastrium level or even greater level of ● Pain worse in supine
● Severe pain radiating to the exertion position and relieved by
back, particularly between ○ This is when patients sitting upright and leaning
shoulder pains perform a certain activity, forward
○ Acute aortic dissection like climbing a flight of ○ Pericarditis
● Radiation to the trapezius stairs, and they find relief ● Pain exacerbated by alcohol,
ridge when they further climb food or reclined portion
○ Characteristic of up the stairs. ○ Gastroesophageal
pericardial pain ● Postprandial angina: reflux (GERD)
redistribution of blood flow ● Exacerbation by eating
from coronary artery tree to ○ GI etiology
the splanchnic vasculature ● Pain constant in intensity for
after eating triggers chest prolonged period (hours to
pain days) unlikely MI
○ Only occurs in patients ○ No signs of hemodynamic
with severe CAD compromise.
○ Usually when patients ○ If it occurs in the absence
complain of chest pain of abnormal ECG
after eating, you think of elevated cardiac
GI problems like acid biomarkers or clinical
reflux, peptic ulcer sequelae (heart failure or
disease, so you have to hypotension) (PPT Notes)
look at the timing of the
Figure 2. Chest pain characteristics and its association in MI
pain
● According to Harrisons, radiation to right arm and shoulders has ● Relief within minutes of
the highest likelihood ratio for having actual MI nitroglycerin is suggestive
○ So far, I haven’t yet seen an MI patient who complained of of MI
chest pain radiating to the right arm or shoulder ○ Esophageal spasm can
also be relieved by
Pattern of Pain nitroglycerin.
Table 4. History taking of chest discomfort: Pattern of Pain ○ Do a thorough history
Likely MI Less Likely MI taking to distinguish MI
● Discomfort builds over ● Pain that reaches its peak and esophageal spasm
minutes and exacerbated by intensity immediately
activity and mitigated by rest ○ Aortic dissection, PE, Associated Symptoms
spontaneous
Table 6. History taking of chest discomfort: Associated Symptoms
pneumothorax
○ Usually patients complain Likely MI Less Likely MI
of sudden, severe chest ● Diaphoresis, dyspnea, ● Sudden onset of significant
pain fatigue, faintness, and respiratory distress =
● Fleeting pain (few seconds) eructation pulmonary conditions such
is rarely ischemic ○ May exist in isolation as as PE or Spontaneous
● Pain constant in intensity for anginal equivalents (i.e. Pneumothorax
prolonged period (hours to symptoms of MI other ● Syncope or presyncope:
days) unlikely MI than typical angina) (PPT hemodynamically significant
○ No signs of hemodynamic
notes)
pulmonary embolism or
compromise ○ Seen particularly in aortic dissection
○ If it occurs in the absence women and elderly ○ Syncope presyncope can
of abnormal ECG ● Nausea and vomiting may also consider ischemic
elevated cardiac occur in the setting of MI arrhythmia (PPT notes)
biomarkers or clinical (commonly Inferior MI) part ● Nausea and vomiting
○ GI disorder

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of the Bezold-Jarisch ● Levine’s sign

Reflex ○ Patients massaging or clutching their chests may describe their
pain with a clenched fist held against the sternum (Harrison’s);
Past Medical History associated with chest pain of MI
● History of connective tissue disease such as Marfan syndrome ● Body habitus
○ Prone to acute aortic syndrome or spontaneous pneumothorax ○ e.g. young tall thin man with sudden onset of chest pain, a bit of
● Clues of depression or prior panic attacks dyspnea, unilateral absence of breath sounds: consider
○ Chest pain could be psychological spontaneous pneumothorax
● Useful in assessing the patient for risk factors for coronary
atherosclerosis and venous thromboembolism and conditions that
may predispose them to specific disorder (PPT notes)

NEED-TO-KNOW :
● Postprandial angina
○ Occurs in patients with severe CAD
○ Redistribution of blood flow to the splanchnic vasculature
after eating triggers chest pain
● Likely MI: Diaphoresis, dyspnea, fatigue, faintness, and
eructation
○ May exist in isolation as anginal equivalents, particularly in
women and elderly
● Nausea and vomiting may occur in the setting of MI (commonly
Inferior MI) part of the Bezold-Jarisch Reflex Figure 3. Levine’s sign associated with chest pain of MI.
● “Warm up angina”
○ Relief from angina as they continue at the same level or even Vital Signs
greater level of exertion ● Significant tachycardia and hypotension
○ Hemodynamic consequences of the underlying cause of the
CONCEPT CHECKPOINT: chest pain, should prompt rapid survey for the most severe
● What cardiovascular condition should you consider when the conditions
patient complains of chest pain after eating? ■ Such as acute MI with cardiogenic shock, massive PE,
● What are the symptoms in Likely MI that are anginal equivalents pericarditis with tamponade (Harrison’s)
in women and elderly? ○ If presented with a patient who is already hypotensive, you
● Type of angina where the patient feels relief as they continue at have to be very fast in trying to diagnose what is the potential
the same level or even greater level of exertion cause of their condition.
● Less likely MI: Condition to be considered when chest pain is ● Severe hypertension
exacerbated with alcohol, food or reclined portion ○ Acute aortic syndromes, but may be also associated with
● Less likely MI: Condition to be considered when chest pain profound hypotension
worse in supine position and relieved by sitting upright and ○ If they start compromising the coronary arterial tree of the heart,
leaning forward then they can have profound hypotension.
● Sinus tachycardia
Answers:
○ Important manifestation of submassive pulmonary embolism
● Postprandial angina
● Tachypnea and hypoxemia
● Diaphoresis, dyspnea, fatigue, faintness, and eructation
○ Pulmonary cause
● Warm up angina
● Gastroesophageal reflux (GERD) Pulmonary
● Pericarditis ● Examination of the lungs may localize a primary cause of chest
discomfort
C. PHYSICAL EXAM
○ e.g. crackles on one side and other history fits pneumonia,
● Provide an initial assessment of patient’s clinical stability could be just pneumonia
● Provide direct evidence of: (PPT notes) ● Pulmonary edema
○ Specific etiologies of chest pain ○ Left ventricular dysfunction from severe ischemia/infarction as
■ e.g. Unilateral absence of lung sounds: pneumothorax well as acute valvular complications of MI or aortic dissection;
○ Potential precipitants of acute causes of chest pain an indicator of high risk (Harrison’s)
■ e.g. Uncontrolled hypertension: MI, acute aortic dissections
○ Comorbid conditions Cardiac
■ e.g. COPD: pneumothorax ● Jugular Venous Pressure
○ Complications of the presenting syndrome ○ Often normal in patients with acute MI, but have characteristic
■ e.g. Heart failure; hypotensive (already with hemodynamic patterns with pericardial tamponade or acute RV dysfunction
compromise such as in life-threatening conditions of aortic ● S3 or S4
dissection, MI, or pulmonary embolism) ○ Reflects systolic or diastolic dysfunction; murmurs may be
● However, because the findings on PE may be normal in patients present (e.g. MI )
with unstable ischemic heart disease, an unremarkable PE is not ○ Murmur of MR (Mitral Regurgitation) or VSD (Ventricular Septal
definitively reassuring (Harrison’s) Defect) - mechanical complication of STEMI (PPT notes)
○ Murmur of AR (aortic regurgitation)
General Appearance
■ May be a complication of proximal aortic dissection (PPT notes)
● Anxious, uncomfortable, pale, cyanotic, diaphoretic ● Pericardial friction rub
○ Acute MI or other acute cardiopulmonary disorders ○ Reflects pericarditis

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○ Resembles sound produced when rubbing hair between fingers ● Acute limb ischemia with loss of pulses and pallo, particularly in
near ear; “scratchy” sound upon chest auscultation the upper extremities is a consequence of what disease?
Abdominal ● It is a rare, inflammatory disorder characterized by chest pain
● Localizing tenderness of abdomen may identify a GI cause and swelling of one or more of the upper ribs (costochondral
junction).
Vascular Answers:
● Pulse deficits ● Levine’s sign
○ Reflect underlying chronic atherosclerosis ● F. Hypotension should prompt rapid survey for the most severe
conditions, as it indicates hemodynamic consequences of the
● Acute limb ischemia with loss of pulses and pallor (pale, cold underlying cause of the chest pain.
to touch ), particularly in upper extremities ● Tachypnea and hypoxemia
○ Consequence of aortic dissection ● Pericardial friction rub
● Localizing tenderness of the abdomen
● Unilateral leg swelling
● Aortic dissection
○ Venous thromboembolism ● Tietze syndrome
■ History of deep vein thrombosis (DVT) may predispose
patients to have pulmonary embolism C. DIAGNOSTICS
Musculoskeletal Electrocardiography (ECG)
● Pain arising from palpation of the costochondral and ● Simple; usually the first diagnostic test ordered
chondrosternal joints/ articulations, may be associated with ● Must be obtained within 10 minutes of presentation
localized swelling, redness or marked localized tenderness ● Crucial in the evaluation of non-traumatic chest pain
○ May be dealing with costochondritis (tenderness of the ● Primary goal: identify patients with STEMI for immediate
costochondral junctions) revascularization
■ Tietze syndrome ● Serial ECG
● Rare, inflammatory disorder characterized by chest pain ○ Done every 30 - 60 minutes
and swelling of one or more of the upper ribs ○ Recommended in the ER for evaluation of suspected Acute
(costochondral junction) Coronary Syndrome (ACS)
● Pain on palpation of these joints is usually well-localized and a ■ If ECG reading is non-specific/normal in the first try, it might
useful clinical sign, though deep palpation may elicit pain in the be an evolving MI
absence of costochondritis (Harrison’s) ● Possible ECG findings to look for:
○ Although palpation of the chest wall often elicits pain in patients Table 7. Possible ECG Findings
with musculoskeletal conditions, chest wall tenderness does Diagnosis ECG Findings
not exclude MI
● ST Segment depression
● Sensory deficits in upper extremities: cervical disk disease
NSTEMI ● Symmetric T-wave inversion at least 0.2 mV in
NEED-TO-KNOW : depth
● Levine’s Sign ● Sinus tachycardia
○ Patients massaging or clutching their chests may describe ● Rightward axis deviation
Pulmonary
their pain with a clenched fist held against the sternum; ● SIQIII TIII
Embolism
associated with chest pain of MI ○ S-wave in lead I, Q wave and T-wave in lead
● Significant tachycardia and hypotension III
○ Indicate hemodynamic consequences of the underlying cause ● Diffuse ST segment elevation not
of the chest pain and prompt rapid survey for the most severe corresponding to a specific coronary artery
Pericarditis
conditions (such as acute MI with cardiogenic shock, massive distribution
PE, pericarditis with tamponade) ● PR segment depression
● Examination of the lungs may localize a primary cause of chest Chest X-ray
discomfort
● Ordered for acute chest discomforts
● Localizing tenderness of abdomen may identify a GI cause
● Most useful for identifying pulmonary process that may be causing
● Tietze syndrome
the chest discomfort
○ Rare, inflammatory disorder characterized by chest pain and
○ To rule out pneumonia or pneumothorax
swelling of one or more of the upper ribs (costochondral
● Often unremarkable in ACS but patient may present with
junction)
pulmonary edema
● Although palpation of the chest wall often elicits pain in patients
● Possible Chest X-ray findings to look for:
with musculoskeletal conditions, chest wall tenderness does not
○ Aortic dissection: Widening of mediastinum
exclude MI
○ Pulmonary embolism: Hampton’s Hump/ Westermark's
sign
CONCEPT CHECKPOINT:
○ Chronic Pericarditis: Pericardial calcification (Harisson’s)
● What sign is associated with chest pain of MI, wherein patients
can be seen massaging or clutching their chests and may Cardiac Biomarkers
describe their pain with a clenched fist held against the sternum? ● Troponin: for the diagnosis of MI
● T/F: A patient presenting with hypertension should prompt rapid ○ Measured in all patients with suspected ACS at presentation
survey for the most severe conditions. ○ Repeated in 3-6 hours, if needed
● What vital signs point to a pulmonary cause of chest pain? ○ Has superior cardiac tissue specificity as compared to CK-MB
● What cardiac PE finding is expected in a patient with
pericarditis? ● Diagnosis of MI
● What PE finding points to a GI cause of chest pain? ○ Reserved for acute myocardial injury that is marked by a rising
or falling pattern

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○ With at least one value exceeding the 99th percentile reference Significant ST-depression 2
limit ECG Non-specific abnormality 1
○ Caused by ischemia Normal 0
≥ 65 years old 2
Provocative Testing For Ischemia Age 45 to <65 years old 1
● Exercise ECG “Stress Testing” < 65 years old 0
○ For completion of risk stratification of patients who have ≥ 3 risk factors 2
undergone initial evaluation that has not revealed a specific Risk factors 1 to 2 risk factors 1
cause of chest discomfort and identified them as having low or None 0
selectively intermediate risk of ACS (PPT notes) ≥ 3 x 99th percentile 2
Troponin
○ If you’ve done a thorough history and PE, and the laboratory 1 to < 3 x 99th percentile 1
(serial)
diagnostic tests are normal, but you still suspect that the ≤ 99th percentile 0
patient may still be having an ischemic type of chest pain TOTAL
■ Order tests which provoke ischemia, namely the Exercise Low risk: 0-3
ECG Not low risk: ≥ 4
● Early exercise testing is safe in patients without high risk findings
after 8-12 hours of observation NICE-TO-KNOW:
■ Patient must be stable and chest pain-free ● Troponin (Serial) Scoring (American Academy of Family Physicians)
Table 8. Exercise ECG ○ 2: ≥ 3 times the normal limit
Patient Condition Description ○ 1: 1 to < 3 times the normal limit
Pharmacologic stress testing with ○ 0: ≤ the normal limit
If patient is unable ● 99th percentile/upper reference limit: highest value seen in 99%
either nuclear perfusion imaging or
to exercise of a reference population not suffering from MI (Harrison's)
echocardiography
If patient has ○ 99th percentile upper limit of cardiac troponin: 14
Stress testing is contraindicated nanograms/L(American College of Cardiology, American Heart Foundation)
ongoing chest pain
Table 11. North American Chest Pain Rule
Other Non-Invasive Studies
North American Chest Pain Rule
Table 9. Other Non-Invasive Studies High Risk Criteria Yes/No
Procedure Description Typical symptoms for ischemia
● Detection of abnormal regional wall ECG: acute ischemic changes
Echocardiography motion for possible ischemic
Age ≥ 50 years old
dysfunction
Known coronary artery disease
● Sensitive technique for detection of
Troponin (serial) > 99th percentile
coronary disease (proximal third of the
Low Risk: All No
major epicardial arteries)
CT Angiography Not low risk: Any Yes
● Can exclude aortic dissection,
pericardial effusion, and pulmonary
embolism
● Cardiac MRI for structural and
functional evaluation of the heart and
Figure 3. Examples of decision-aids used in conjunction with serial
MRI vasculature of the heart measurement of cardiac troponin for evaluation of acute chest pain
● Usually not practical for the urgent (see appendix)
evaluation of chest pain
NEED-TO-KNOW :
Integrative Decision Aids
● ECG
● Clinical algorithms have been developed to aid in decision making ○ Used to identify patients with STEMI
during the evaluation and disposition of patients with acute ● Chest X-ray: for patients presenting w/ acute chest discomforts
non-traumatic chest pain (PPT notes) ○ Aortic dissection: Widening of mediastinum
● Estimate probability of: (PPT notes) ○ Pulmonary embolism: Hampton’s Hump/Westermark's sign
○ Final diagnosis of ACS ● Cardiac Biomarker
○ Major cardiac event during short term follow up ○ Troponin (for diagnosis of MI)
● Decision aids are used most commonly to identify patients with ● Integrative decision aids
low clinical probability of ACS who are candidates for early ○ HEART Score and North American Chest Pain Rule
provocative testing (e.g. stress testing) or for early discharge from ● Exercise ECG: “stress testing”
the ER ○ Use of pharmacologic stress testing for Px unable to exercise
● Examples of Integrative Decision Aids: ○ Contraindicated for patients with ongoing chest pain
○ Heart Score ● REMEMBER: Good health history is important to help
■ Each letter corresponds to a component within the decision diagnose chest discomfort of patients
aid (PPT notes)
○ North American Chest Pain Rule CONCEPT CHECKPOINT:
Table 10. HEART Score ● What is the diagnostic test done every 30-60 minutes for patients
HEART Score with suspected STEMI?
Highly suspicious 2 ● T/F. Echocardiography must be obtained within 10 minutes of
History Moderately suspicious 1 presentation of symptoms.
Slightly suspicious 0

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● Westermark’s sign was seen on the patient’s X-ray. What is the Goal
possible disease associated with the findings? ● Determine whether the symptom is caused by a life threatening
● What are the components of the HEART Score? arrhythmia
● Give examples of other non-invasive studies which can be used
History
to diagnose patients presenting with chest pain?
Answers: ● Coronary Artery Disease
● Serial ECG ○ Do they have the risk factors?
● False. It’s ECG (electrocardiography) not echocardiography. ○ Have they been diagnosed with this disease?
● Pulmonary embolism ● Other associated symptoms:
● History, ECG, Age, Risk factors, Troponin (serial)
● Echocardiography, CT Angiography, MRI ○ Syncope
○ Lightheadedness
IV. PALPITATIONS ● Some patients may not present with associated symptoms
○ Do a background history of conditions
● Unusual awareness of the heart beat
● Patients with no or unremarkable past medical history
● “Thumping”, “pounding”, or “fluttering” sensation in the chest
○ Further investigation through diagnostic tests
● Intermittent or sustained
● Regular or irregular Physical Examination
● Often noted when the patient is quietly resting, when other stimuli ● Vital signs
are minimal (Harrison’s) ● Jugular venous pressure and pulse
A. CAUSES ● Auscultation of precordium
○ You have to know the rhythm of the heart to determine if they
● Cardiac (43%) are actually presenting with palpitations
● Psychiatric (31%) ○ Not conclusive; needs further testing because some patients
● Miscellaneous (10%) may not have palpitations upon examination
● Unknown (16%)
Diagnostics
Cardiac Causes ● ECG
● Intermittent palpitation ○ To document the arrhythmia
○ Premature atrial contraction (PAC) ● Exercise ECG
○ Premature ventricular contraction (PVC) ○ Stress Testing
● Regular sustained palpitation ■ If exertion is known to induce arrhythmia and accompanying
○ Supraventricular tachycardia (SVT) palpitations
○ Ventricular tachycardia (VT) ● Continuous ECG (Holter) Monitoring
● Irregular sustained palpitation ○ Test for infrequent episodes of palpitations
○ Atrial fibrillation ○ Attempt to “catch” or record the episodes of palpitations
● Loop recordings (external and implantable)
NEED-TO-KNOW : ● Mobile cardiac outpatient telemetry
● Most arrhythmias are not associated with palpitations
NEED-TO-KNOW :
Other Causes ● To rule out arrhythmia, always ask for history of Coronary artery
● Catecholaminergic stimulation disease
○ Exercise ● Common diagnostic parameters for palpitation are ECG, Stress
○ Stress ECG, and Holter monitoring test
○ Pheochromocytoma
● Athletes (Harrison’s) CONCEPT CHECKPOINT:
● Aortic regurgitation (Harrison’s) ● What is the most common cause of palpitations?
○ Enlarged ventricle ● T/F: Substances that enhance myocardial contraction can cause
○ Accompanying hyperdynamic precordium palpitation as well.
● Substances that enhance the strength of myocardial contraction Answers:
○ Tobacco, caffeine, aminophylline, atropine, thyroxine, cocaine, ● Cardiac
amphetamines ● T
Psychiatric Causes
V. EDEMA
● Panic or Anxiety disorder
● Longer duration of sensation (>15 minutes) and other ● Excess interstitial fluid that is clinically evident
accompanying symptoms ● “Pitting” edema
○ Persistent indentation of the skin after pressure is applied
Miscellaneous Causes
● Anasarca
● Thyrotoxicosis (Harrison’s) ○ Gross generalized edema
○ Excessive quantities of thyroid hormones due to overproduction ● Ascites
by the thyroid gland ○ Excess fluid in the peritoneal cavity
● Drugs ○ Special form of edema (Harrison’s)
● Ethanol ● Hydrothorax
● Spontaneous muscle contractions of the chest wall ○ Excess fluid in the pleural cavities
● Systemic mastocytosis ○ Special form of edema (Harrison’s)
B. APPROACH TO PALPITATION ● Net movement of fluid from the intravascular to the interstitial
space due to the following conditions:

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○ Increase in intracapillary hydrostatic pressure 3. Nephrotic Syndrome and other hypoalbuminemic states
○ Inadequate lymphatic drainage ○ Diminished colloid oncotic pressure due to losses of large
○ Reduced oncotic pressure in the plasma quantities (≥3.5 g/d) of protein into the urine, and
○ Damage to the capillary endothelial barrier hypoalbuminemia (<3.0 g/dL)
○ Increase in oncotic pressure in the interstitial space ○ The edema is diffuse, symmetric, and most prominent in the
dependent areas; periorbital edema is most prominent in the
A. APPROACH TO EDEMA
morning.
● First approach is to determine if it is a localized or generalized form 4. Hepatic Cirrhosis
of edema ○ Hepatic venous outflow obstruction, which in turn expands the
1. Localized splanchnic blood volume, and hepatic lymph formation
● Local phenomena should be identified as the cause ○ Early stage: Ascites
● Causes: ○ Later stage: Peripheral edema due to severe hypoalbuminemia
○ Thrombophlebitis ■ Ascitic fluid may increase intraabdominal pressure and
○ Varicose veins impede venous return from the lower extremities
○ Primary venous valve failure 5. Drug-Induced Edema
● Lymphedema ○ NSAIDs and Cyclosporine: renal vasoconstriction
○ Chronic lymphangitis, parasitic infection such as filariasis, ○ Vasodilators: arteriolar dilation
history of resection of lymph nodes (e.g. after breast surgery) ○ Steroid Hormones: augmented renal sodium reabsorption
○ Capillary damage
2. Generalized 6. Edema of Nutritional Origin
● Systemic or bilateral ○ Prolonged protein and calorie deficiency → hypoproteinemia
● Cardiac, renal, hepatic, or nutritional disorders are usually and edema
responsible ■ Intensified by the development of beriberi heart disease
● Determine if with hypoalbuminemia (serum albumin <3 g/dl) ○ Edema develops or becomes intensified when famished
○ History subjects are first provided with an adequate diet
○ PE and lab ■ Refeeding edema
■ To evaluate for nephrotic syndrome, liver cirrhosis, or severe ● Increased food intake increases the quantity of sodium
malnutrition ingested, which is then retained along with water.
● No hypoalbuminemia ● Increased release of insulin, which directly increases
○ Is there evidence or history of heart conditions? (e.g. heart tubular sodium reabsorption
failure)
● Consequently, the differential diagnosis of generalized edema NEED-TO-KNOW :
Table 12. Principal Causes of Generalized Edema: History, Physical
should be directed toward identifying or excluding these several Examination, and Laboratory Findings. Abbreviations: CRF = chronic
conditions. renal failure; NS = nephrotic syndrome
Differential Diagnosis of Generalized Edema (Harrison’s) Organ Physical Laboratory
History
● Read over features of HF, hepatic cirrhosis, renal disease, and System Examination Findings
nutritional (PPT) Elevated jugular
venous
1. Heart Failure
pressure,
○ The impaired systolic emptying of the ventricle(s) and/or the
ventricular (S3) Elevated urea
impairment of ventricular relaxation promotes an accumulation Dyspnea with
gallop; nitrogen-to-creati
of blood in the venous circulation at the expense of the effective exertion
occasionally with nine ratio
arterial volume prominent -
displaced or common; serum
○ Activation of the sympathetic nervous system and RAAS cause often associated
Cardiac dyskinetic apical sodium often
with orthopnea -
renal vasoconstriction and reduction of glomerular filtration and pulse; diminished;
or paroxysmal
salt and water retention, blood volume accumulates in the peripheral elevated
nocturnal
venous circulation, raising venous and intracapillary pressure cyanosis, cool natriuretic
dyspnea
resulting in edema extremities, peptides
○ Usually occurs in dependent portions of the body small pulse
○ Manifestations: pressure when
■ Overt cardiac disease severe
● Cardiac enlargement and/or ventricular hypertrophy, Frequently If severe,
associated with reductions in
together
ascites; serum albumin,
■ Clinical evidence
Dyspnea jugular venous cholesterol, other
● Dyspnea, basilar rales, venous distention, and uncommon, pressure normal hepatic proteins
hepatomegaly → indicates edema results from heart except if or (transferrin,
failure associated with low; blood fibrinogen); liver
2. Edema of renal disease Hepatic significant pressure lower enzymes
○ Commonly results from primary retention of sodium and water degree of than in elevated,
by the kidneys owing to renal dysfunction. ascites; most renal or cardiac depending on
○ Edema that occurs during the acute phase of often a history disease; one or the cause and
glomerulonephritis is characteristically associated with of ethanol abuse more acuity
hematuria, proteinuria, and hypertension additional signs of liver injury;
○ This state differs from most forms of heart failure in that it is of chronic liver tendency toward
characterized by a normal (or sometimes even increased) disease hypokalemia,
cardiac output

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(jaundice, respiratory ● Renal (Nephrotic Syndrome)

palmar alkalosis; ● T
erythema, macrocytosis
Dupuytren’s from B. DISTRIBUTION OF EDEMA
contracture, folate deficiency
Table 13. Distribution of Edema
spider
Distribution Description
angiomata, male
gynecomastia; ● More extensive in the legs and
asterixis and accentuated in the evening.
Heart Failure
other signs ● Prominent in presacral region if patient is
of confined to the bed
encephalopathy) ● Generalized edema but evident in the very
may be present soft tissues of eyelids & face and more
Usually chronic: pronounced in the morning (PPT) owing to
may be the recumbent posture assumed during
associated with the night (Harrison’s)
uremic ● Edema resulting from hypoproteinemia
signs and
occurs in nephrotic syndrome (Harrison’s)
symptoms,
Elevation of
including
Elevated blood serum creatinine Nephrotic
decreased
pressure; and cystatin Syndrome
appetite, altered
hypertensive C; albuminuria;
(metallic or
retinopathy; hyperkalemia,
fishy) taste,
Renal nitrogenous metabolic
altered
(CRF) fetor; pericardial acidosis,
sleep pattern,
friction rub in hyperphosphate
difficulty
advanced cases mia,
concentrating,
with hypocalcemia,
restless
uremia anemia (usually
legs, or Figure 4. Facial Edema brought about by
normocytic) Nephrotic syndrome
myoclonus;
dyspnea can be ● Tiichinosis, myxedema, allergic reactions
present, but Facial Edema ● Look into history of medications or
generally less exposure to certain parasites
prominent than ● Venous and/or lymphatic obstruction,
in heart failure unilateral paralysis
Proteinuria (≥3.5 ● Unilateral paralysis reduces lymphatic &
g/d); venous drainage on the affected side and
Childhood
hypoalbuminemi can cause unilateral edema (PPT Notes)
diabetes Periorbital
Renal a;
mellitus; plasma edema; ● If the patient has a history of stroke,
(NS) hypercholesterol
cell hypertension edema can occur on the side of paralysis
emia;
dyscrasias because of reduced lymphatic and venous
microscopic
hematuria One Leg drainage
or
One or Both
CONCEPT CHECKPOINT: Arms
● What is the organ system involved if a patient presents with
generalized edema, prominent dyspnea with exertion, elevated
JVP, (+) ventricular S3 gallop, elevated urea
nitrogen-to-creatinine ratio, and elevated natriuretic peptides?
● T/F: A hepatic cause of generalized edema is suspected when
patient has a history of ethanol abuse, has a history of ascites,
normal JVP, hyperkalemia, metabolic acidosis, and
microcytosis? Figure 5. Lymphatic Obstruction
● What is the cause of generalized edema if a patient presents ● Obstruction of the superior vena cava
with childhood DM, periorbital edema, hypertension, proteinuria, ● In patients with obstruction of the superior
hyperalbuminemia, hypercholesterolemia, and microscopic vena cava, edema is confined to the face,
hematuria? neck, and upper extremities in which the
● T/F: Chronic renal failure is suspected to be the cause of venous pressure is elevated compared
generalized edema if there is a history of altered sleep pattern. Edema Confined with that in the lower extremities (Harrison’s)
PE presents with elevated BP and hypertensive retinopathy. Lab to Face, Neck, & ● If a patient presents with a possible history
findings show elevated serum creatinine and cystatin C, Upper Extremity of CA or enlarged cervical lymph nodes,
albuminuria, hyperkalemia, and metabolic acidosis. this may be causing superior vena cava
Answers: syndrome (SVC Syndrome)
● Cardiac ● Patient presents with facial edema and the
● F - hypokalemia, respiratory alkalosis, and microcytosis from neck seems swollen. After treatment,
folate deficiency patient goes back to normal

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● You have to look into the history of the Resolves after stopping medication
patient
Table 15. Drug Induced Edema (Mentioned in the Lecture)
Drug/s Effect/s
NSAIDs & cyclosporine Renal vasoconstriction
Vasodilators Arteriolar dilatation
Augmented renal sodium
Steroid hormones
reabsorption

NICE-TO-KNOW:
● Drugs associated with edema formation (Harrison’s)
○ Nonsteroidal anti-inflammatory drugs
○ Antihypertensive agents
○ Direct arterial/arteriolar vasodilators
○ Hydralazine
Figure 6. SVC Syndrome ■ Clonidine
■ Methyldopa
NEED-TO-KNOW :
■ Guanethidine
● Heart failure
■ Minoxidil
○ Edema is more extensive in the legs, or in presacral region if
○ Calcium channel antagonists
the patient is confined to the bed, and is accentuated in the
○ α-Adrenergic antagonists
evening
○ Thiazolidinediones
● Nephrotic syndrome
○ Steroid hormones
○ Generalized edema but evident in eyelids, face, and more
■ Glucocorticoids
pronounced in the morning
■ Anabolic steroids
● Facial edema
■ Estrogens
○ Due to trichinosis, myxedema, or allergic reactions
■ Progestins
● 1 leg or 1/both arms
○ Cyclosporine
○ Edema due to venous and/or lymphatic obstruction or
○ Growth hormone
unilateral paralysis
○ Immunotherapies
● Superior vena cava syndrome (SVC syndrome)
■ Interleukin 2
○ Obstruction of the superior vena cava presents with edema
■ OKT3 monoclonal antibody
confined to the face, neck, and upper extremities
NEED-TO-KNOW :
CONCEPT CHECKPOINT:
● Hypothyroidism (myxedema)
● T/F: Edema due to heart failure is more extensive in the upper
○ Deposition of hyaluronic acid
extremities and accentuated in the morning
● Hyperthyroidism (pretibial myxedema secondary to Grave's
● T/F: Nephrotic syndrome presents with unilateral edema
disease)
● Name 3 causes of facial edema
○ Non pitting edema
● What is the distribution of edema due to venous and/or lymphatic
obstruction or unilateral paralysis?
CONCEPT CHECKPOINT:
● What is the distribution of edema due to SVC syndrome?
● Hyaluronic acid deposition is a hallmark of what condition that
Answers causes edema?
● F - legs and accentuated in the evening ● T/F: Non-pitting edema is caused by hypothyroidism
● F - generalized edema but evident in eyelids, face, and more ● T/F: Edema caused by vasodilators, namely Dihydropyridines
pronounced in the morning (e.g. Nifedipine & Amlodipine), does not resolve after stopping
● Trichinosis, myxedema, and allergic reactions medication
● 1 leg or 1/both arms ● NSAIDs & cyclosporine results in ___ causing edema
● Edema confined to face, neck, and upper extremities ● Steroid hormones cause edema by augmenting which biologic
process?
C. OTHER CAUSES OF EDEMA Answers
Table 14. Other Causes of Edema ● Hypothyroidism (myxedema)
Cause Description ● F - Hyperthyroidism (pretibial myxedema secondary to Grave’s
Hypothyroidism disease)
Deposition of hyaluronic acid ● F - Resolves after stopping medication
(myxedema)
● Renal vasoconstriction
Hyperthyroidism
● Augmented renal sodium reabsorption
(pretibial myxedema
Non-pitting edema
secondary to Grave's
V. REFERENCES
disease)
Exogenous Kasper, D. L., & Harrison, T. R. (2018). Harrison's Principles of
- Internal Medicine. New York: McGraw-Hill, Medical Pub. Division.
hyperadrenocorticism Azares. (2019). Approach to Edema, Chest Pain, & Palpitations
Pregnancy Causes lower extremity edema [lecture powerpoint].
Dihydropyridines
Vasodilators e.g. Nifedipine, Amlodipine

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b. Cervical disk disease

VI. REVIEW QUESTIONS
c. Esophageal reflux
LE 3 2021 (Different lecturer) d. Esophageal rupture
11. A 64/F with previous history of deep vein thrombosis
1. What is the primary consideration in a 55/M hypertensive complained of sudden pleuritic chest pain associated
with sudden episode of unrelenting anterior chest pain with cough after long haul travel. At the ER, BP is at
characterized as tearing or ripping? 80/60 mmHg, RR 28, O2 sat 79% at room air. What is her
a. Acute Aortic Syndrome likely diagnosis?
b. Acute coronary syndrome a. Acute coronary syndrome
c. Pericarditis b. Acute dissection
d. Pulmonary embolism c. Pneumonia
2. Which of the following conditions, associated with d. Pulmonary embolism
palpitations, presents with the greatest risk for 12. What is the most common cause of nontraumatic chest
ventricular arrhythmias? discomfort that mimics acute myocardial infarction?
a. Pre-existing significant coronary artery disease a. Aortic aneurysm
b. Psychiatric disorder b. Chest wall syndrome
c. Severe aortic regurgitation c. GERD
d. Thyrotoxicosis d. Pericarditis
3. What is the principal goal in assessing patients with 13. Which among the following is the most common etiology
palpitations? of palpitations?
a. Determine whether the symptoms are life threatening a. Cardiac
b. Examine if the symptoms is associated with heart attack b. Endocrine
c. Know if the patient has thyroid problem c. Hematologic
d. Know if the patient needs a psychiatric consult as he is d. Psychiatric
only malingering 14. Which of the following diagnostic tests must be ordered
4. What characterizes edema associated with heart failure? in a patient with acute chest discomfort at the ER?
a. Evident in the very soft tissues of the eyelids and face a. Echocardiography
b. Extensive in the legs and more accentuated in the evening b. Chest x-ray
c. Limited to one leg or to one or both arms c. ESR
d. Pronounced in the morning d. ABGs
5. Which of the following medications causes edema? 15. A 24/M presented with palpitations lasting for more than
a. Ace inhibitors 15 minutes and usually experiences this every time he
b. Beta blockers would attend his tutorial class. He drinks coffee 3x a day
c. Cephalosporins and takes Vitamin C as his maintenance medications.
d. NSAIDs What is the most common cause of his condition?
6. A 50-year old hypertensive, diabetic, 30-pack smoker a. Drug induced
presented with crushing chest pain relieved by rest. ECG b. Panic disorder
showed a non-specific ST-T wave changes. Serial c. Premature ventricular contractions
troponin is more than thrice than normal. What is his d. Thyrotoxicosis
HEART score? 16. In the approach to a patient with edema, what is the first
a. 4 question to ask?
b. 6 a. Is the edema localized or generalized?
c. 8 b. Is there a change in urine volume?
d. 10 c. What are the associated signs and symptoms?
7. When is the best time to extract cardiac troponin in a d. What are the current medications being taken?
63/F consulting the ER because of 5-hour history of 17. Which of the following is a special form of edema?
chest heaviness? a. Anasarca
a. 1 hour upon arrival at the ER b. Ascites
b. 6 hours upon arrival at the ER c. Myxedema
c. 8 hours after onset of chest pain d. Pericardial effusion
d. Upon arrival at the ER 18. Which of the following causes of edema is brought about
8. Which group of patients may present with atypical by damage to the capillary epithelium?
myocardial infarction? a. NSAIDs
a. Determine whether the symptoms life threatening b. Heart failure
b. Elderly women c. Thrombophlebitis
c. Smokers d. Venous obstruction
d. Young people For nos. 19-22: Match the numbered organ system with the
9. Which of the following associated symptoms has the corresponding lettered history/PE/laboratory findings
highest probability of developing myocardial infarction? below. Choice may be used once, multiple times, or not at
a. Diaphoresis all.
b. Epigastric pain A. Normal jugular venous pressure
c. Radiation to the right arm or shoulder B. Periorbital edema
d. Radiation to the left arm C. Cool extremities
10. Which non-cardiopulmonary cause of chest pain has the D.Metabolic acidosis
greatest urgency to deteriorate rapidly? 19. Cardiac
a. Bleeding peptic ulcer 20. Hepatic

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21. Chronic Renal Failure a. Myocardial infarction

22. Metabolic acidosis b. Myocarditis
c. Stable angina
Answers: (1) A, (2) A, (3) A, (4) B, (5) D, (6) C, (7) D, (8) B, (9) C, (10) D, (11) D, (12) C, d. Unstable angina
(13) A, (14) B, (15) B, (16) A, (17) B, (18) A, (19) C, (20) A, (21) D, (22) B
10. How many minutes is the chest discomfort associated
LE 3 2020 (Different lecturer) with myocardial infarction typically lasts?
a. 2 to 9
1. Which of the following is NOT a common concerning
b. > 10
sign or symptom in the cardiovascular system?
c. > 20
a. Chest pain
d. > 30
b. Edema
11. Which of the following statements is true regarding the
c. Nape pain
characteristic pain of pericarditis?
d. Palpitations
a. Involvement of the pleural surface of the lateral diaphragm
2. Which of the following diagnosis is life-threatening in
can lead to pain in the subscapular area
patient with chest pain?
b. It is rarely caused by infectious etiologic agent
a. Dissecting aortic aneurysm
c. Pain of pericarditis arises principally from inflammation of
b. GERD
the visceral and parietal pericardium
c. Pulmonary hypertension
d. Pain of pleural pericarditis is often referred to the shoulder
d. Stable Angina
and neck area
3. What potent peptide vasoconstrictor elevates in patients
12. A 55/F house helper consulted the emergency room
with severe heart failure and contributes to renal
complaining of abrupt onset of chest pain and shortness
vasoconstriction, sodium retention and edema?
of breath. An ECG done showed ST-elevation at V1-V6
a. Arginine vasopressin
and an echocardiography done revealed basal
b. Dopamine
hyperkinesis and severe hypokinesia of the mid to apical
c. Endothelin-1
left ventricular segments. What is your primary
d. Natriuretic peptide
consideration?
4. What is a common laboratory finding in cases of
a. Acute MI
nephrotic syndrome?
b. Broken heart syndrome
a. Elevated cystatin C
c. Chronic stable angina
b. Hypokalemia
d. Restrictive cardiomyopathy
c. Hypercholesterolemia
13. What acute aortic syndrome is characterized by
d. Respiratory alkalosis
disruption in the aortic intima, resulting in the separation
5. What substance directly increases tubular sodium
of the media and creation of a separate lumen?
reabsorption and is seen in Refeeding edema?
a. Acute aortic dissection
a. Aldosterone
b. Intramural hematoma
b. Endothelin
c. Penetrating aortic ulcer
c. Glucocorticosteroids
d. Traumatic aortic injury
d. Insulin
14. What is the mechanism of chest pain in cases of small
6. A 45-year-old female consulted because of regular,
pulmonary emboli?
sustained palpitations. What is the primary
a. Distention of the pulmonary artery
consideration?
b. Involvement of the pleural space of the lung adjacent to the
a. Atrial fibrillation
pulmonary infarct
b. Premature atrial depolarization
c. RV wall stress
c. Psychiatric cause
d. Subendocardial ischemia related to pulmonary
d. Supraventricular tachycardia
hypertension
7. A 35-year-old male consulted for recurrent palpitations
15. What is the most common cause of non-traumatic chest
lasting for more than 15 mins associated with episodes
discomfort?
of hyperventilation, circumoral numbness and feeling
a. Chest wall syndrome
like going to pass out. What is the primary
b. Gastrointestinal cause
consideration?
c. Ischemic heart disease
a. Anxiety disorder
d. Psychiatric causes
b. Cardiac cause
16. What condition is associated with chest pain resulting
c. Pheochromocytoma
from transmural esophageal rupture caused by severe
d. Thyrotoxicosis
vomiting?
8. What is a safe and cost-effective diagnostic modality in
a. Boerhaave syndrome
the assessment of patients with recurrent, unexplained
b. Esophageal spasm
palpitations?
c. Mallory-Weiss syndrome
a. Electrocardiogram
d. Peptic ulcer disease
b. Exercise electrocardiogram
17. What condition manifests with pain described as an
c. Holter monitoring
intense, squeezing discomfort that is retrosternal on
d. Loop recorder
location and relieved by dihydropyridine calcium
9. 60/M, known hypertensive and diabetic, consulted the ER
channel antagonist?
complaining of recurrent chest tightness on climbing
a. Costochondritis
2-flight of stair, lasting for 5 mins and relieved
b. Esophageal spasm
immediately with rest. What is your primary
c. Pericarditis
consideration?
d. Stable angina

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18. Which of the following ECG finding can aid in 21. What laboratory test is useful as a rule-out test in
distinguishing pericarditis from acute myocardial patients with a low or moderate pretest likelihood for
infarction? pulmonary embolism?
a. PR-segment depression a. D-dimer
b. Rightward shift of the axis b. Myoglobin
c. ST segment elevation V1-V6 with corresponding reciprocal c. N-type natriuretic peptide
change d. Troponin I
d. None of the above 22. A 38/F, known case of SLE, consulted the ER for
19. How many minutes upon presentation of the patient with unilateral leg swelling of one week. What is the primary
chest pain should an ECG should be obtained? consideration?
a. 10 a. Acute limb ischemia
b. 20 b. Lymphedema
c. 30 c. Peripheral arterial occlusive disease
d. 40 d. Venous thromboembolism
20. Early exercise testing is commonly employed for
completion of risk stratification of patients with chest Answers: (1) C, (2) A, (3) C, (4) C, (5) D, (6) D, (7) A, (8) D, (9) C, (10) D, (11) D, (12) B,
(13) A, (14) B, (15) B, (16) A, (17) B, (18) A, (19) A, (20) B, (21) A, (22) D
discomfort. How many hours after observation is it safe
to perform it in patients without high-risk findings?
a. 6 hours
b. 8 - 12 hours
c. 12 - 24 hours
d. 48 hours
SUMMARY

CONCEPT CHECKPOINT

● T/F: The onset/duration of myocardial infarction is usually and may describe their pain with a clenched fist held
> 30 minutes. against the sternum?
○ T ○ Levine’s sign
● What are the three categories of chest pain? ● T/F: A patient presenting with hypertension should prompt
○ (1) Myocardial ischemia, (2) other cardiopulmonary causes, rapid survey for the most severe conditions.
(3) non-cardiopulmonary causes ○ F. Hypotension should prompt rapid survey for the most
● Chest pain that occurs at a lower intensity of physical severe conditions, as it indicates hemodynamic
activity, and is described to be accelerating consequences of the underlying cause of the chest pain.
○ Unstable angina ● What vital signs point to a pulmonary cause of chest pain?
● T/F: Most common discharge diagnosis for chest pain is ○ Tachypnea and hypoxemia
ischemic heart disease. ● What cardiac PE finding is expected in a patient with
○ F. Gastrointestinal disorders (42%). Ischemic heart disease pericarditis?
accounts for only 31% ○ Pericardial friction rub
● Condition which is often associated with tearing, ripping, ● What PE finding points to a GI cause of chest pain?
or knifelike characteristic of pain ○ Localizing tenderness of the abdomen
○ Acute aortic syndrome (aortic dissection). Refer to table 1 ● Acute limb ischemia with loss of pulses and pallo,
(appendix) particularly in the upper extremities is a consequence of
● Described as unilateral, often localized, pleuritic chest pain what disease?
with associated dyspnea, cough, fever, and rales. ○ Aortic dissection
○ Pneumonia or pleuritis. Refer to table 1 (appendix) ● It is a rare, inflammatory disorder characterized by chest
● What cardiovascular condition should you consider when pain and swelling of one or more of the upper ribs
the patient complains of chest pain after eating? (costochondral junction).
○ Postprandial angina ○ Tietze syndrome
● What are the symptoms in Likely MI that are anginal ● What is the most common cause of palpitations?
equivalents in women and elderly? ○ Cardiac
○ Diaphoresis, dyspnea, fatigue, faintness, and eructation ● T/F: Substances that enhance myocardial contraction can
● Type of angina where the patient feels relief as they cause palpitation as well.
continue at the same level or even greater level of exertion ○ T
○ Warm up angina ● What is the diagnostic test done every 30-60 minutes for
● Less likely MI: Condition to be considered when chest pain patients with suspected STEMI?
is exacerbated with alcohol, food or reclined portion ○ Serial ECG
○ Gastroesophageal reflux (GERD) ● T/F. Echocardiography must be obtained within 10 minutes
● Less likely MI: Condition to be considered when chest pain of presentation of symptoms.
worse in supine position and relieved by sitting upright and ○ False. It’s ECG (electrocardiography) not echocardiography.
leaning forward ● Westermark’s sign was seen on the patient’s X-ray. What is
○ Pericarditis the possible disease associated with the findings?
● What sign is associated with chest pain of MI, wherein ○ Pulmonary embolism
patients can be seen massaging or clutching their chests ● What are the components of the HEART Score?
○ History, ECG, Age, Risk factors, Troponin (serial)

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● Give examples of other non-invasive studies which can be ● T/F: Nephrotic syndrome presents with unilateral edema
used to diagnose patients presenting with chest pain? ○ F - generalized edema but evident in eyelids, face, and more
○ Echocardiography, CT Angiography, MRI pronounced in the morning
● What is the organ system involved if a patient presents ● Name 3 causes of facial edema
with generalized edema, prominent dyspnea with exertion, ○ Trichinosis, myxedema, and allergic reactions
elevated JVP, (+) ventricular S3 gallop, elevated urea ● What is the distribution of edema due to venous and/or
nitrogen-to-creatinine ratio, and elevated natriuretic lymphatic obstruction or unilateral paralysis?
peptides? ○ 1 leg or 1/both arms
○ Cardiac ● What is the distribution of edema due to SVC syndrome?
● T/F: A hepatic cause of generalized edema is suspected ○ Edema confined to face, neck, and upper extremities
when patient has a history of ethanol abuse, has a history ● Hyaluronic acid deposition is a hallmark of what condition
of ascites, normal JVP, hyperkalemia, metabolic acidosis, that causes edema?
and microcytosis? ○ Hypothyroidism (myxedema)
○ F - hypokalemia, respiratory alkalosis, and microcytosis from ● T/F: Non-pitting edema is caused by hypothyroidism
folate deficiency ○ F - Hyperthyroidism (pretibial myxedema secondary to
● What is the cause of generalized edema if a patient Grave’s disease)
presents with childhood DM, periorbital edema, ● T/F: Edema caused by vasodilators, namely
hypertension, proteinuria, hyperalbuminemia, Dihydropyridines (e.g. Nifedipine & Amlodipine), does not
hypercholesterolemia, and microscopic hematuria? resolve after stopping medication
○ Renal (Nephrotic Syndrome) ○ F - Resolves after stopping medication
● T/F: Chronic renal failure is suspected to be the cause of ● NSAIDs & cyclosporine results in ___ causing edema
generalized edema if there is a history of altered sleep ○ Renal vasoconstriction
pattern. PE presents with elevated BP and hypertensive ● Steroid hormones cause edema by augmenting which
retinopathy. Lab findings show elevated serum creatinine biologic process?
and cystatin C, albuminuria, hyperkalemia, and metabolic ○ Augmented renal sodium reabsorption
acidosis.
○ T
● T/F: Edema due to heart failure is more extensive in the
upper extremities and accentuated in the morning
○ F - legs and accentuated in the evening

NEED-TO-KNOW CONCEPTS

I. Chest Pain ● Severity of pain has poor diagnostic accuracy. Asking about
● 3 Categories of Chest pain: Myocardial ischemia, other the similarity of discomfort to previous definite ischemic
cardiopulmonary causes, non-cardiopulmonary causes symptoms is helpful
● Myocardial ischemia/injury: Clinical characteristics of angina ● Quality of Pain: Severity of pain has poor diagnostic
are highly similar for stable ischemic heart disease, accuracy. Asking about the similarity of discomfort to
unstable angina, or myocardial ischemia/injury. The only previous definite ischemic symptoms is helpful
difference is seen in the pattern and duration of the ● Less likely MI: Pericarditis - Pain worse in supine position
symptoms and relieved by sitting upright and leaning forward
II. Angina ● Less likely MI: Gastroesophageal reflux (GERD) - Pain
● Chest discomfort of myocardial ischemia/injury is typically exacerbated by alcohol, food or reclined portion
aching, heavy, squeezing, crushing, or constricting ● Postprandial angina: Occurs in patients with severe CAD;
● Retrosternal - Site of discomfort redistribution of blood flow to the splanchnic vasculature
● Radiation is common and generally down to the ulnar after eating triggers chest pain
surface of the left arm, right arm, both arms, neck or ● Likely MI: Diaphoresis, dyspnea, fatigue, faintness, and
shoulders eructation and may exist in isolation as anginal equivalents,
● Types of Angina: Stable, Unstable particularly in women and elderly
● Stable Angina - Begins gradually and reaches its maximal ● Nausea and vomiting may occur in the setting of MI
intensity over a period of minutes before resolving within (commonly Inferior MI) part of the Bezold-Jarisch Reflex
several minutes with rest or nitroglycerin ● Warm up angina: Relief from angina as they continue at the
● Unstable Angina - Accelerating type of chest pain, cardiac same level or even greater level of exertion
biomarkers are normal, ECG is unremarkable ● Levine’s Sign: Patients massaging or clutching their chests
III. Myocardial Ischemia/Injury may describe their pain with a clenched fist held against the
● More severe chest discomfort, prolonged (lasting > 30 sternum; associated with chest pain of MI
minutes) ● Significant tachycardia and hypotension: Indicate
● Not relieved by rest hemodynamic consequences of the underlying cause of the
● (+) Troponin or CK MB levels chest pain and prompt rapid survey for the most severe
IV. Approach to Chest Discomfort conditions (such as acute MI with cardiogenic shock, massive
● High risk conditions: non-cardiopulmonary conditions such PE, pericarditis with tamponade)
as esophageal rupture, hold the greatest urgency for ● Examination of the lungs may localize a primary cause of chest
diagnosis discomfort
● Localizing tenderness of abdomen may identify a GI cause

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● Tietze syndrome - rare, inflammatory disorder characterized ● Common diagnostic parameters for palpitation are ECG,
by chest pain and swelling of one or more of the upper ribs Stress ECG, and Holter monitoring test
(costochondral junction) ● Heart failure
● Although palpation of the chest wall often elicits pain in ○ Edema is more extensive in the legs, or in presacral region if
patients with musculoskeletal conditions, chest wall tenderness the patient is confined to the bed, and is accentuated in the
does not exclude MI evening
● ECG - used to identify patients with STEMI ● Nephrotic syndrome
● Chest X-ray - for patients presenting w/ acute chest ○ Generalized edema but evident in eyelids, face, and more
discomforts pronounced in the morning
○ Aortic dissection: Widening of mediastinum ● Facial edema
○ Pulmonary embolism: Hampton’s Hump/Westermark's ○ Due to trichinosis, myxedema, or allergic reactions
sign ● 1 leg or 1/both arms
● Cardiac Biomarker - Troponin (for diagnosis of MI) ○ Edema due to venous and/or lymphatic obstruction or
● Integrative decision aids - HEART Score and North American unilateral paralysis
Chest Pain Rule ● Superior vena cava syndrome (SVC syndrome)
● Exercise ECG - “stress testing” ○ Obstruction of the superior vena cava presents with edema
○ Use of pharmacologic stress testing for Px unable to confined to the face, neck, and upper extremities
exercise ● Hypothyroidism (myxedema)
○ Contraindicated for patients with ongoing chest pain ○ Deposition of hyaluronic acid
● Most arrhythmias are not associated with palpitations ● Hyperthyroidism (pretibial myxedema secondary to Grave's
● To rule out arrhythmia, always ask for history of Coronary disease)
artery disease ○ Non pitting edema

Table 12. Principal Causes of Generalized Edema: History, Physical Examination, and Laboratory Findings. Abbreviations: CRF = chronic renal
failure; NS = nephrotic syndrome
Organ System History Physical Examination Laboratory Findings
Elevated jugular venous pressure,
ventricular (S3) gallop; occasionally Elevated urea nitrogen-to-creatinine
Dyspnea with exertion prominent -
with displaced or dyskinetic apical ratio common; serum sodium often
Cardiac often associated with orthopnea -
pulse; peripheral cyanosis, cool diminished; elevated natriuretic
or paroxysmal nocturnal dyspnea
extremities, peptides
small pulse pressure when severe
Frequently associated with ascites;
jugular venous pressure normal or
If severe, reductions in serum albumin,
low; blood pressure lower than in
cholesterol, other hepatic proteins
Dyspnea uncommon, except if renal or cardiac disease; one or more
(transferrin, fibrinogen); liver enzymes
associated with significant degree of additional signs of chronic liver
Hepatic elevated, depending on the cause and
ascites; most often a history of ethanol disease (jaundice, palmar erythema,
acuity of liver injury; tendency toward
abuse Dupuytren’s contracture, spider
hypokalemia, respiratory alkalosis;
angiomata, male gynecomastia;
macrocytosis from folate deficiency
asterixis and other signs of
encephalopathy) may be present
Usually chronic: may be associated
with uremic signs and symptoms,
Elevation of serum creatinine and
including decreased appetite, altered Elevated blood pressure; hypertensive
cystatin C; albuminuria; hyperkalemia,
(metallic or fishy) taste, altered sleep retinopathy; nitrogenous fetor;
Renal (CRF) metabolic acidosis,
pattern, difficulty concentrating, pericardial friction rub in advanced
hyperphosphatemia, hypocalcemia,
restless legs, or myoclonus; dyspnea cases with uremia
anemia (usually normocytic)
can be present, but generally less
prominent than in heart failure
Proteinuria (≥3.5 g/d);
Childhood diabetes mellitus; plasma hypoalbuminemia;
Renal (NS) Periorbital edema; hypertension
cell dyscrasias hypercholesterolemia; microscopic
hematuria

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APPENDIX

Figure 7. Clinical conditions in which a decrease in cardiac output (A) and systemic vascular resistance (B) cause arterial underfilling with
resulting neurohumoral activation and renal sodium and water retention. In addition to activating the neurohumoral axis, adrenergic stimulation
causes renal vasoconstriction and enhances sodium and fluid transport by the proximal tubule epithelium. RAAS, renin-angiotensin aldosterone
system; SNS, sympathetic nervous system. (Harrison’s)

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Table 1a. Typical Clinical Features of Major Causes of Acute Chest Discomfort: Cardiopulmonary
System Condition Onset/Duration Quality Location Associated Features
CARDIOPULMONARY
Myocardial ischemia Stable angina: Pressure, tightness, Retrosternal; often S4 gallop or mitral regurgitation
Precipitated by squeezing, heaviness, radiation to neck, jaw, murmur (rare) during pain; S3
exertion, cold, or burning shoulders, or arms; or rales if severe ischemia or
stress; 2-10 min sometimes epigastric complication of myocardial
infarction
Unstable angina:
Increasing pattern or
Cardiac
at rest

Myocardial
infarction:
Usually >30 minutes
Pericarditis Variable; hours to Pleuritic, sharp Retrosternal or toward May be relieved by sitting up
days; may be episodic cardiac apex; may and leaning forward; pericardial
radiate to left shoulder friction rub
Acute aortic syndrome Sudden onset of Tearing or ripping, Anterior chest, often Associated with hypertension
unrelenting pain knifelike radiating to back and/or underlying connective
between shoulder tissue disorder; murmur of
blades aortic insufficiency; loss of
peripheral pulses
Vascular Pulmonary embolism Sudden onset Pleuritic; may manifest Often lateral, on the Dyspnea, tachypnea,
as heaviness with side of the embolism tachycardia, and hypotension
massive pulmonary
embolism
Pulmonary Variable; often Pressure Substernal Dyspnea, signs of increased
hypertension exertional venous pressure
Pneumonia or pleuritis Variable Pleuritic Unilateral, often Dyspnea, cough, fever, rales,
localized occasional rub
Pulmonary Spontaneous Sudden onset Pleuritic Lateral to side of Dyspnea, decreased breath
pneumothorax pneumothorax sounds on the side of
pneumothorax

Table 2a. Typical Clinical Features of Major Causes of Acute Chest Discomfort: Non-cardiopulmonary
System Condition Onset/Duration Quality Location Associated Features
NON-CARDIOPULMONARY
Esophageal reflux 10-60 minutes Burning Substernal, Worsened by postprandial
epigastric recumbency; relieved by antacids
Esophageal spasm 2-3 minutes Pressure, tightness, Retrosternal Can closely mimic angina
burning
Peptic ulcer Prolonged; 60-90 Burning Epigastric, Relieved with food or antacids
Gastrointestinal minutes after meals substernal
Gallbladder disease Prolonged Aching or colicky Epigastric, right May follow meal
upper quadrant;
sometimes to the
back
Costochondritis Variable Aching Sternal Sometimes swollen, tender, warm
over joint; may be reproduced by
localized pressure on examination
Cervical disease Variable; may be Aching; may include Arms and shoulders May be exacerbated by movement
Neuromuscular sudden numbness of neck
Trauma or strain Usually constant Aching Localized to area of Reproduced by movement or
strain palpation
Herpes Zoster Usually prolonged Sharp or burning Dermatomal Vesicular rash in area of discomfort
distribution
Emotional and Variable; may be Variable; often Variable; may be Situational factors may precipitate
psychiatric feeling or prolonged manifests as retrosternal symptoms; history of panic attacks,
Psychological conditions tightness and depression
dyspnea with feeling
of panic or doom

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Table 3a. History Taking of Chest Discomfort

Criteria Likely MI Less Likely MI
● Pressure or tightness ● Pleuritic discomfort
○ Typical of myocardial ischemic pain ○ Process involving pleura, pericarditis, PE or
● Some patients with ischemic chest symptoms deny pulmonary process
any “PAIN” but complain of dyspnea or vague sense ● “Tearing” “ripping”
Quality of
of anxiety ○ Acute aortic dissection
Pain
■ It is a very severe pain. It’s like something is
sliding down their back and ripping them.
● Burning quality
○ Acid reflux or peptic ulcer disease
● Substernal location with radiation to neck, jaw, ● Highly localized
shoulders or arms typical of MI. ● Retrosternal location
● Radiation to both arms ○ Esophageal pain
○ High association with MI as etiology ● Pain solely above the mandible or below the
● I have never seen MI patient who can pinpoint the area epigastrium
Location of of the chest, usually it is something underneath (behind ● Severe pain radiating to the back, particularly between
Discomfort their sternum/something deep). They (MI patients) shoulder pains
cannot localized the pain. ○ Acute aortic dissection
● Radiation to the trapezius ridge
○ Characteristic of pericardial pain
● If the patient is able to point to the area of the pain, less
likely that you might be dealing with MI.
● Discomfort builds over minutes and exacerbated by ● Pain that reaches its peak intensity immediately
activity and mitigated by rest ○ Aortic dissection, PE, spontaneous pneumothorax
○ Usually patients come in with pain so severe
● Fleeting pain (few seconds) is rarely ischemic
● Pain constant in intensity for prolonged period (hours to
Pattern of Pain
days) unlikely MI
○ No signs of hemodynamic compromise.
○ If it occurs in the absence of abnormal ECG
elevated cardiac biomarkers or clinical sequelae
(heart failure or hypotension) (PPT Notes)
● Chest pain usually starts with exertion ● Alterations in intensity of pain with changes in position
● Prefer to rest, sit or stop walking or movement of the upper extremities or neck
● Be aware of “Warm up angina” - relief from angina as ○ Musculoskeletal origin (eg: cervical disk disease)
they continue at the same level or even greater level of ● Pain worse in supine position and relieved by sitting
exertion upright and leaning forward
○ This is when patients perform a certain activity, like ○ Pericarditis
climbing a flight of stairs, and they find relief when ● Pain exacerbated by alcohol, food or reclined portion
they further climb up the stairs. ○ Gastroesophageal reflux (GERD)
● Postprandial angina - setting of severe coronary ● Exacerbation by eating
Provoking and atherosclerosis, redistribution of blood flow to the ○ GI etiology
Alleviating splanchnic vasculature after eating triggers chest pain ● Pain constant in intensity for prolonged period (hours to
Factors days) unlikely MI
○ Only occurs in patients with severe coronary artery ○ No signs of hemodynamic compromise.
disease. Usually when patients complain of chest ○ If it occurs in the absence of abnormal ECG
pain after eating, you think of GI problems like acid elevated cardiac biomarkers or clinical sequelae
reflux, peptic ulcer disease, so you have to look at (heart failure or hypotension) (PPT Notes)
the timing.
● Relief within minutes of nitroglycerin is suggestive of
MI
○ Esophageal spasm can also be relieved by
nitroglycerin.
● Diaphoresis, dyspnea, fatigue, faintness, and ● Sudden onset of significant respiratory distress =
eructation pulmonary conditions such as Pulmonary Embolism
○ May exist in isolation as anginal equivalents, (PE) or Spontaneous Pneumothorax
particularly in women and elderly ● Syncope or presyncope - hemodynamically significant
● Nausea and vomiting may occur in the setting of MI pulmonary embolism or aortic dissection
Associate
(commonly Inferior MI) part of the Bezold-Jarisch ○ Syncope presyncope can also consider ischemic
Symptoms
Reflex arrhythmia (PPT notes)
● Nausea and vomiting
○ GI disorder
● Anginal equivalent
● e.g. symptoms of MI other than typical angina (PPT notes)

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