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MedEd Tutorials > 10. Chest Pain WORK ON THIS!! use don notes and meded notes > Flashcards

10. Chest Pain WORK ON THIS!! use don notes and meded notes Flashcards

1
Q

What is IHD?

A

Decreased blood supply to the heart muscle causing heart pain
Split into
Stable Angina and ACS

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2
Q

What are the three ACS’?

A

Unstable angina
STEMI
NSTEMI

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3
Q

What is stable angina?

A

Chest pain predictably with exertion.

Caused by narrowed arteries in the heart,

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4
Q

Investigations with stable angina?

A 
Resting ECG (pathologic Q wave, wide or deep)
Lipid profile and glucose for risks
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5
Q

Managing stable angina?

A

Educate
Dual antiplatelet (aspirin and clopidogrel)
Statin

GTN spray for pain and beta blocker/CCB

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6
Q

Unstable angina presents?

A

Chest pain occurs RANDOMLY

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7
Q

Investigations in unstable angina?

A 
ECG (no changes)
Troponins
CXR
FBC 
GRACE score
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8
Q

Treating unstable angina?

A 
300mg loading dose of aspirin (continue indefinitely)
Add antithrombin (fondaparinux)

Low GRACE - ticagrelor and aspirin (+ clop if bleeding risk)
High GRACE - angiography if unstable, maybe PCI (tig and asp after)

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9
Q

NSTEMI vs STEMI?

A

STEMI has ST elevation and troponins

NSTEMI only has troponins which is why it is not unstable angina

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10
Q

NSTEMI symptoms and treatment?

A 
Chest pain
Sweating
SOB
Nausea
Upper back pain

Treat same as unstable angina

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11
Q

ECG in NSTEMI?

A

ST depression and T wave inversion

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12
Q

STEMI presentation?

A

Severe crushing chest pain
Sweating
SOB
Pallor

If diabetic/elderly may be silent heart attack

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13
Q

Extra investigation for STEMI than NSTEMI?

A

Coronary angiography

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14
Q

ECG changes in STEMI?

A

Hyperacute T waves and ST elevation with LBBB

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15
Q

How to detect bundle branch block?

A

WILLIAM - LBBB the Q wave looks like a W on V1, M on V6

MARROW - other way around

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16
Q

How to manage STEMI?

A

Symptoms <12 hrs + PCI possible in <2hrs

  • Angio and PCI (In 2hrs)
  • Clopidogrel and aspirin if taking anticoagulants
  • Prasugrel and aspirin if not
  • Plus antithrombins

Symptoms <12hrs + PCI not possible in 2hrs

  • Fibrinolysis (alteplase and antithrombin)
  • Aspirin and clopidogrel
  • Offer ECG 60-90 minutes after drugs, angio and PCI if changes persist
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17
Q

STEMI complications?

A 
Death
Arrhythmia
Rupture through wall, septum or papillary
Tamponade
Heart failure
Valvular disease
Aneurysm
Dressler's syndrome (pericarditis two weeks or after stemi)
Embolism Reccurence

DARTH VADER

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18
Q

What is pericarditis?

A

Inflammation of the pericardium (sac around heart)

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19
Q

Causes of pericarditis?

A

Inflammation - post-mi (dressler’s), systemic (sarcoid, SLE), trauma
Infection - viral e.g. TB, mumps, coxsackie
Malignancy - malignancy, anti-cancer drugs

20
Q

Signs and symptoms of pericarditis?

A

Short periods of sharp pleuritic chest pain usually post-viral
Relieved by sitting up and leaning forward
Worse on deep breaths and coughing
Pericardial friction rub on auscultation (scratchy, left sternal edge on expiration)

Often fever, dyspnoea and nausea

21
Q

What is cardiac tamponade + becks triad? (comp of pericarditis)

A 
Fluid buildup in the pericardium that restricts pumps.
Beck's triad - 
Distended neck veins
Decreased BP (haemo unstable, below 90)
Distorted heart sounds
22
Q

Investigations for pericarditis?

A

Bloods - troponins (ACS rule out), CRP, FBC (see any infection), LFTs (check for tamponade
ECG saddle-shaped ST elevation
CXR - globular heart if effusion is present

23
Q

How do we manage pericarditis?

A

NSAIDs, PPI, colchicine (gout meds) and exercise restrict if viral or idiopathic

Give ABx and pericardiocentesis (in tamponade) if purulent

If recurrent consider pericardiectomy

24
Q

What is AF?

A

Supraventricular tachycardia with inappropriate electrical activity and ineffective contraction.
Lots of causes including valve disease, hyperthyroidism, hypertension etc.

25
Q

Types of AF?

A

Paroxysmal - stops within 7 days
Persistent - more than 7 days
Permanent - cannot achieve sinus rhythm

26
Q

Signs and symptoms of AF?

A 
Irregularly irregular pulse
Palpitations
Chest pain
SOB
Fatigue
27
Q

Investigations in AF?

A

ECG (absent p waves and irreg irreg)
Bloods for cause
Echo
Stroke risk with CHADS-VASc

28
Q

How to long term manage AF?

A

CHADS-VASc
>1 then offer doac
=1 then consider
If contraindicated then offer with vitamin K antagonist
Higher score means higher risk of stroke means more likely needing doac

29
Q

Short term treating AF?

A

Haemodynamic instability? DC cardioversion
Less than 48 and haemodynamic stability? Offer rate and rhythm control
Rhythm would be DC cardioversion or pharmacolofical e.g. amiodarone or flecainide (no IHD)

30
Q

HERE How do you rate control a patient?

A

Beta blocker
Rate-limiting CCB
Add digoxin if poorly controlled

31
Q

What is atrial flutter?

A

Signs and symptoms of AF that are faster and more regular than AF.

32
Q

Wolff-parkinson-white (WPW) syndrome is?

A

An accessory pathway of electrical signals called the bundle of kent. Associated with ebstein’s abnormality where tricuspid leaflets are displaced.

33
Q

Signs and symptoms of WPW?

A

Palpitations
Chest pain
SOB
Syncope

34
Q

Investigations and treatment of WPW?

A

ECG - delta wave (slurred upstroke), broad QRS and short PR
Echo for ebsteins/HOCM

DC cardioversion to treat if unstable
Stable - 
1. Vagal manoeuvres
2. IV Adenosine
3. Temporary pacemaker
4. DC cardioversion
35
Q

What is a supraventricular tachycardia?

A

Narrow complex tachy that is regular

Two types AVNRT (electrical circuit incorrect) and AVRT (the tissue is malfunctioning WPW is a subtype).

36
Q

Investigations for SVT?

A 
ECGs
U&Es
TFTs
Digoxin level
Cardiac enzymes
37
Q

Management of SVT?

A
  1. Valsalva manoeuvre
  2. 6mg adenosine then 12mg in 1-2mins if not effective (x2)
  3. Verapamil
  4. DC cardioversion

Long-term - catheter ablation

38
Q

What is ventricular tachycardia?

A

A regular broad-complex tachycardia

39
Q

Causes/risk factors for SVT?

A

Cardiomyopathy
Coronary artery disease
Electrolyte abnormalities (e.g. low pot, calc, magn)
Drug abuse

40
Q

Signs and symptoms of vtachy?

A 
Syncope/dizziness
Chest pain
SOB
Hypotension/tachy
Sudden death
41
Q

Investigations for vtachy?

A

ECG (broad complex tachy)
U&Es
Troponins and CKMB

42
Q

How would we treat a vtachy?

A

Without a pulse - advanced life support
Unstable with pulse - DC cardioversion
Stable with pulse - IV amiodarone, DC if fail
Torsades de Points - IV magnesium sulfate

43
Q

What is ventricular fibrillation?

A

Irregular, broad-complex tachycardia where the ventricles contract out of sync.

Chest pain
Palpitations
SOB
Nausea/dizziness
Unconscious
44
Q

Investigations for vfib?

A

ECG

ABG - for substance abuse and electrolyte imbalance (pot)

45
Q

How do we treat vfib?

A
  1. Give oxygen
  2. IV 1mg adrenaline every 3-5 minutes
  3. IV 300mg amiodarone after 3 shocks over 3 mins
  4. Treat reversible causes (pot instabilities)
46
Q

What are the four types of heart block?

A

1st degree - prolonged PR interval
Mobitz type I - PR gets longer and longer until QRS is dropped
Mobitz type II - QRS complex dropped at regular ratio
Complete heart block - no association between P and QRS complex

47
Q

How do we treat heart block?

A

Monitor if asymptomatic
Discontinue AV node blockers
Consider pacemaker, CRT (e.g. DC cardioversion), ICD or temporary pacing

MedEd Tutorials (32 decks)

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