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Medicine Y3 TCD 1-12 > 1. Chest pain - Angina and ACS > Flashcards

1. Chest pain - Angina and ACS Flashcards

1
Q

What is angina

A

Narrowing of coronary arteries, reducing blood flow to myocardium so at times of high demand ie exercise there isn’t enough blood supply to the heart

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2
Q

what are the typical symptoms of angina

A

Constricting discomfort in the front of the chest, or in neck, shoulders, jaw or arms

Precipitated by physical exertion

Relieved by rest or GTN within about 5 minutes

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3
Q

when would angina be classified as unstable

A

when the symptoms come on randomly whilst at rest

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4
Q

When investigating angina what is the gold standard investigative procedure

A

CT coronary angiography

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5
Q

Name some of the baseline investigations when trying to diagnose Angina

A
  • Physical Examination (heart sounds, signs of heart failure, BMI)
  • ECG
  • FBC (check for anaemia)
  • U&Es (prior to ACEi and other meds)
  • LFTs (prior to statins)
  • Lipid profile
  • Thyroid function tests (check for hypo / hyper thyroid)
  • HbA1C and fasting glucose (for diabetes)
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6
Q

Name some differential diagnosis of chest pain apart from angina

A

GORD
musculoskeletal pain
anxiety

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7
Q

when should a patient with angina ring for an ambulance

A

Take GTN, then repeat after 5 minutes. If there is still pain 5 minutes after the repeat dose – call an ambulance

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8
Q

What are the long term symptomatic relief options for patients with angina

A

Beta blocker (bisoprolol 5mg once a day) or calcium channel blocker (amlodipine 5mg)

{other options that aren’r t first line are long acting nitrates, ivabradine, nicorandil and ranolazine}

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9
Q

What are the 4 A’s in the secondary prevention of angina

A

Aspirin ( ie 75mg once daily)
atorvastatin 80mg once daily
ACE inhibitor
already on beta-blocker for symptomatic relief

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10
Q

Name 2 procedural/surgical interventions for people with coronary artery disease

A
  1. percutaneous coronary intervention (PCI) with coronary angioplasty by placing catheter in the femoral artery or brachial
  2. Coronary artery bypass graft (CABG)
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11
Q

A patient with a midline sternotomy scar and great saphenous vein harvesting will have had what procedure (think cardiac)

A

coronary artery bypass graft (CABG)

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12
Q

A patient with a brachial artery access scar or femoral artery access scar have had what kind of cardiac procedure

A

percutaneous coronary intervention (PCI)

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13
Q

What is acute coronary syndrome usually a result of

A

a thrombus from an athersclerotic plaque blocking a coronary artery (made up of mostly platelets)

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14
Q

Which coronary artery becomes the circumflex and left anterior descending artery (LAD)

A

left coronary artery

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15
Q

which coronary artery branch supplies the R atrium and ventricle as well as the inferior aspect of the left ventricle and the posterior septal area

A

right coronary artery

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16
Q

which coronary artery branch supplies the left atrium and posterior aspect of the left ventricle

A

circumflex artery

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17
Q

which coronary artery branch supplies the anterior aspect of the left ventricle and the anterior aspect of the septum

A

left anterior descending (LAD) artery

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18
Q

name the 3 types of acute coronary syndromes (ACS)

A

unstable angina
Non-STEMI
STEMI

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19
Q

Making a diagnosis with possible ACS symptoms:

On an ECG if there is ST elevation or new LBBB then what is the diagnosis

A

STEMI

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20
Q

Making a diagnosis with possible ACS symptoms:

If there is no ST elevation on an ECG what investigation should be performed

A

Troponin blood test

21
Q

Making a diagnosis with possible ACS symptoms:

If there are raised troponin levels and/or other ECG changes such as ST depression, T wave inversion or pathological Q waves what should you diagnose

A

NSTEMI

22
Q

Making a diagnosis with possible ACS symptoms:

If troponin levels are normal and the ECG does not show pathological changes what could the diagnosis be

A

unstable angina
or
other causes such as musculoskeletal pain

23
Q

Symptoms of ACS: what accompanying things are associated with the central, constricting chest pain

A 
nausea and vomiting 
sweating and clamminess 
feeling of impending doom
SOB
palpitations 
pain radiating to jaw or arms
24
Q

Symptoms of ACS should continue at rest for more than 20 minutes, what would you consider if they settle

A

angina

25
Q

diabetic patients may not experience typical chest pain during ACS, what is this referred to as

A

silent MI

26
Q

what does a normal ECG not exclude

A

ACS

27
Q

how do you exclude ACS after a normal ECG

A

cardiac troponin test

28
Q

if you suspect ACS what medication do you need to give and at what dose

A

loading dose of aspirin 300mg

29
Q

what are the ECG changes in ACS for a STEMI

A

ST segment elevation in leads consistent with an area of ischemia

30
Q

what are the ECG changes in ACS for a NSTEMI

A

ST segment depression in a region
deep T wave inversion
pathological Q waves

31
Q

Clinical findings in which ECG leads would indicate a LCA blockage which supplies the anterolateral heart

A

I, aVL, V3-6

32
Q

clincal findings in which ECG leads would indicate a LAD blockage which supplies the anterior heart area

A

V1-4

33
Q

clinical findings in which ECG leads would indicate a circumflex artery blockage which supplies the lateral heart area

A

I, aVL, V5-6

34
Q

clinical findings in which ECG leads would indicate a RCA blockage which supplies the inferior heart area

A

II, III, aVF

35
Q

Name some alternative causes of increase troponin levels

A 
chronic renal failure 
sepsis 
myocarditis 
aortic dissection 
PE
36
Q

what are the treatments for an acute STEMI within 12 hours of symptom onset

A 
primary PCI (if available within 2 hours of presentation)
thrombolysis (if PCI not available within 2 hours)
37
Q

name some examples of thrombolysis therapy

A

streptokinase and alteplase

38
Q

What is the treatment of an acute NSTEMI

the mnemonic is BATMAN

A

B- beta blockers
A- aspirin 300 stat dose
T- ticagrelor 180mg stat dose (clopidogrel 300mg is the alternative)
M- morphine titrated to control the pain
A- anticoag such as LMW heparin
N- nitrates (eg GTN) to relieve coronary artery spasm

39
Q

what is the scoring system used to access for PCI in NSTEMI

A

GRACE score
<5% low risk
>10% high risk

40
Q

what are the complications of MI

mnemonic is heart failure DREAD

A 
D- Death 
R- Rupture of the heart septuum or papillary muscles 
E- edema 
A- arrhythmias and aneurysm 
D- dresslets syndrome
41
Q

what is dressler’s syndrome (AKA post-MI syndrome)

A

localised immune response and causes pericarditis

42
Q

what does dressler’s syndrome present with

A

pleuritic chest pain
low grade fever
pericardial rub on auscultation

43
Q

How is dressler’s syndrome diagnosed

A

ECG (global ST elevation and T wave inversion
Echocardiogram (pericardial effusion)
raised inflammatory markers (CRP and ESR)

44
Q

what is the management of dressler’s syndrome

A

NSAIDs (aspirin/ibuprofen) and in more serious cases steroids (prednisolone)

45
Q

Name the 6 As in the secondary prevention medial management of ACS

A

Aspirin 75mg once daily

Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months

Atorvastatin 80mg once daily

ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)

Atenolol (or other beta blocker titrated as high as tolerated)

Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

46
Q

Name some secondary lifestyle preventative measures for ACS

A 
stop smoking 
reduce alcohol 
mediterranean diet 
cardiac rehab 
optimise treatment of other medical conditions
47
Q

Atypical presentation of ACS is common in which age group

A

over 75s

48
Q

troponin levels rise with _______ hours of an infaract or ischemia and may be elevated for up to _____ weeks

A

2-4 hours

2 weeks

49
Q

Treatment of NSTEMI/unstable angina what should youu offer

A

aspirin 300mg stat

fondaparinux (anticoag) if not planning coronary angiography in 24 hours

Medicine Y3 TCD 1-12 (30 decks)

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