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

Question 1

What is IHD?

Answer 1

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

Question 2

What are the three ACS’?

Answer 2

Unstable angina
STEMI
NSTEMI

Question 3

What is stable angina?

Answer 3

Chest pain predictably with exertion.

Caused by narrowed arteries in the heart,

Question 4

Investigations with stable angina?

Answer 4

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

Question 5

Managing stable angina?

Answer 5

Educate
Dual antiplatelet (aspirin and clopidogrel)
Statin

GTN spray for pain and beta blocker/CCB

Question 6

Unstable angina presents?

Answer 6

Chest pain occurs RANDOMLY

Question 7

Investigations in unstable angina?

Answer 7

ECG (no changes)
Troponins
CXR
FBC 
GRACE score

Question 8

Treating unstable angina?

Answer 8

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)

Question 9

NSTEMI vs STEMI?

Answer 9

STEMI has ST elevation and troponins

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

Question 10

NSTEMI symptoms and treatment?

Answer 10

Chest pain
Sweating
SOB
Nausea
Upper back pain

Treat same as unstable angina

Question 11

ECG in NSTEMI?

Answer 11

ST depression and T wave inversion

Question 12

STEMI presentation?

Answer 12

Severe crushing chest pain
Sweating
SOB
Pallor

If diabetic/elderly may be silent heart attack

Question 13

Extra investigation for STEMI than NSTEMI?

Answer 13

Coronary angiography

Question 14

ECG changes in STEMI?

Answer 14

Hyperacute T waves and ST elevation with LBBB

Question 15

How to detect bundle branch block?

Answer 15

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

MARROW - other way around

Question 16

How to manage STEMI?

Answer 16

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

Question 17

STEMI complications?

Answer 17

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

Question 18

What is pericarditis?

Answer 18

Inflammation of the pericardium (sac around heart)

Question 19

Causes of pericarditis?

Answer 19

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

Question 20

Signs and symptoms of pericarditis?

Answer 20

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

Question 21

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

Answer 21

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

Question 22

Investigations for pericarditis?

Answer 22

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

Question 23

How do we manage pericarditis?

Answer 23

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

Give ABx and pericardiocentesis (in tamponade) if purulent

If recurrent consider pericardiectomy

Question 24

What is AF?

Answer 24

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

Question 25

Types of AF?

Answer 25

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

Question 26

Signs and symptoms of AF?

Answer 26

``` Irregularly irregular pulse Palpitations Chest pain SOB Fatigue ```

Question 27

Investigations in AF?

Answer 27

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

Question 28

How to long term manage AF?

Answer 28

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

Question 29

Short term treating AF?

Answer 29

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)

Question 30

HERE How do you rate control a patient?

Answer 30

Beta blocker Rate-limiting CCB Add digoxin if poorly controlled

Question 31

What is atrial flutter?

Answer 31

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

Question 32

Wolff-parkinson-white (WPW) syndrome is?

Answer 32

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

Question 33

Signs and symptoms of WPW?

Answer 33

Palpitations Chest pain SOB Syncope

Question 34

Investigations and treatment of WPW?

Answer 34

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 ```

Question 35

What is a supraventricular tachycardia?

Answer 35

Narrow complex tachy that is regular | Two types AVNRT (electrical circuit incorrect) and AVRT (the tissue is malfunctioning WPW is a subtype).

Question 36

Investigations for SVT?

Answer 36

``` ECGs U&Es TFTs Digoxin level Cardiac enzymes ```

Question 37

Management of SVT?

Answer 37

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

Question 38

What is ventricular tachycardia?

Answer 38

A regular broad-complex tachycardia

Question 39

Causes/risk factors for SVT?

Answer 39

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

Question 40

Signs and symptoms of vtachy?

Answer 40

``` Syncope/dizziness Chest pain SOB Hypotension/tachy Sudden death ```

Question 41

Investigations for vtachy?

Answer 41

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

Question 42

How would we treat a vtachy?

Answer 42

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

Question 43

What is ventricular fibrillation?

Answer 43

Irregular, broad-complex tachycardia where the ventricles contract out of sync. ``` Chest pain Palpitations SOB Nausea/dizziness Unconscious ```

Question 44

Investigations for vfib?

Answer 44

ECG | ABG - for substance abuse and electrolyte imbalance (pot)

Question 45

How do we treat vfib?

Answer 45

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)

Question 46

What are the four types of heart block?

Answer 46

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

Question 47

How do we treat heart block?

Answer 47

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