1. Chest Pain Flashcards
A 76-year-old woman is brought into A&E with central crushing chest pain that radiates to her jaw and left arm. An ECG is performed, which shows ST elevation in leads ll, lll and aVF. Her SaO2 is 89%. Before she is sent to the cathlab for percutaneous coronary intervention, she is started on a combination of drugs. Which of the following should not be given? A Morphine B Oxygen C Aspirin D Clopidogrel E Warfarin
E: Warfarin
Warfarin causes an initial pro-thrombotic phase because it blocks protein C and protein S. Therefore, heparin must be co-administered with warfarin to begin with, until the INR stabilises (between 2-3).
Stable Angina Definition
Chest pain resulting from myocardial ischaemia that is precipitated by exertion and relieved by rest.
Most common cause = Atherosclerotic disease
Name 3 rare types of Angina and explain what they are
Decubitus angina – symptoms occur when lying down
Prinzmetal angina – symptoms caused by coronary vasospasm
Coronary syndrome X – symptoms of angina but with normal exercise tolerance and normal coronary angiograms
Management of Stable Angina
Conservative:
- Stop smoking
- Lose weight
- Exercise
Medical:
- Anti-anginals (BB/CCB)
- Symptomatic (GTN spray)
- RF reduction (aspirin, statins, ACEi)
Define ACS
Acute Coronary Syndrome: a constellation of symptoms caused by sudden reduced blood flow to the heart muscle. (ECG and troponin normal)
- Unstable Angina Pectoris: chest pain at rest due to ischaemia without cardiac injury
- Non-ST elevation MI (troponin raised)
- ST-elevation MI
Symptoms of ACS
Acute-onset central, crushing chest pain Radiates to arms/neck/jaw Pallor Sweating NOTE: silent infarcts in elderly and diabetics
Investigations for ACS
ECG
STEMI: Hyperacute T waves, ST elevation, new-onset LBBB
UAP/NSTEMI: ST depression, T wave inversion
Old Infarct: pathological Q waves
Troponins
Elevated troponins suggests myocardial injury (i.e. STEMI or NSTEMI)
ECG leads and site of infarct
Inferior (right coronary artery): II, III, aVF
Anterior (left anterior descending): V1-V5
Lateral (left circumflex): I, aVL, V5/6
Posterior (posterior descending): tall R wave + ST depression in V1-3
Management of ACS - General
Morphine Oxygen Nitrates Antiplatelets (aspirin + clopidogrel) Beta-blockers ACE inhibitors Statins Heparin
STEMI treatment
AIM: Coronary reperfusion either by PCI or fibrinolysis
Patient presenting < 12 hours from onset of symptoms:
Send to cathlab for PCI if it can happen within 120 mins of the time that fibrinolysis could have been administered
Patient presenting > 12 hours from onset of symptoms
Coronary angiography followed by PCI if indicated
NSTEMI/UAP Management
Immediate
- Aspirin + other antiplatelet (e.g. clopidogrel, ticagrelor)
- Fondaparinux – if low bleeding risk unless coronary angiography planned within 24 hrs of admission
- LMWH – if coronary angiography is planned
Risk Stratify using GRACE score HIGH risk GlpIIb/IIIa inhibitor (e.g. tirofiban) Coronary angiography (within 72 hours) LOW risk Conservative management (control risk factors)
Complications of ACS
DARTH VADER Death Arrhythmia Re-infarction Tamponade Heart Failure
Valve disease Aneurysm Dressler's Syndrome Enbolism Rupture
Complications of ACS
DARTH VADER Death Arrhythmia Re-infarction Tamponade Heart Failure
Valve disease Aneurysm Dressler's Syndrome Enbolism Rupture
Define pericarditis and state 5 causes
Inflammation of the pericardium
Causes: Idiopathic Infective (e.g. Coxsackie B) Connective tissue disease (e.g. sarcoidosis) Dressler Syndrome (2-10 weeks after MI) Malignancy
Symptoms and Signs of pericarditis
Sharp, central chest pain Pleuritic Relieved by sitting forward Fever/flu-like symptoms (if viral) Pericardial friction rub Tamponade (if pericardial effusion)
