16. Patient with Chest Pain Flashcards
What are the 3 main things used to make a diagnosis?
- history
- examination
- investigations
What questions should be asked about pain in history taking?
S ite: location of the pain and if it radiates
Q uality: how pain feels (e.g. sharp, dull)
I ntensity: effect on patient, severity score
T iming: when it started; sudden or gradual onset
A ggravating factors: what makes pain worse
R elieving factors: what makes pain better
S econdary symptoms: other symptoms
What may be causes of chest pain?
• Cardiac – Non-ischaemic e.g. pericarditis – Ischaemic…and infarction (disease relating to coronary arteries) • Non-cardiac – Respiratory – Gastro-intestinal – Musculoskeletal
Give examples of musculoskeletal conditions that can cause chest pain.
costochondritis, rib fracture
Give an example of a skin condition that can cause chest pain.
Shingles
How might chest pain caused by musculoskeletal condition present?
- well localised
- may be history of trauma
- sharp pain
- tenderness to plapataion
- exacerbated by deep breathing, coughing
mimics pleuritic chest pain
Give a examples of respiratory conditions that can cause chest pain.
Pneumonia, pulmonary embolism, pleurisy
- due to irritation of pleura
How might chest pain caused by lung or pleura present?
PLEURITIC CHEST PAIN:
- lateral chest pain
- sharp pain (if it involves the pleura)
- localised
- exacerbated by deep breathing, coughing, laughing, sneezing etc
- worsened with positional movement
- would also have other symptoms like fever, cough, SOB, sputum
Give an example of an aortic condition that can cause chest pain.
Aortic dissection
Aortic dissection
- sharp, tearing pain
- radiating to the back
Give an example of an GI condition that can cause chest pain.
Acid reflux, peptic ulcer disease
- burning chest pain
What might be examples of cardiac causes of chest pain?
- myocardial infraction
- stable/unstable angina
- pericarditis
How might chest pain caused by the heart present?
- central chest pain
- dull/crushing (usually cardiac tissue itself, rather than the pericardium)
- less well localised
- radiation to jaw, shoulders, arms
- affected by movement
- visceral pain
- worsened with exertion
Differentiate between a cardiac and a pleuritic chest pain
Cardiac chest pain (visceral) is characterisised by a dull and poorly localised pain in the chest.
Its exacerbated with exertion but it usually reverts at rest.
This type of pain relates to the heart muscle or the coronary arteries.
It can radiate to the shoulder and the jaw. It’ll be found at the centre of the chest but it’s poorly localised.
Pleuritic chest pain(somatic) is characterised by a sudden and intense sharp, stabbing or burning pain in the chest.
This’ll be when the patient is inhaling or exhaling.
It’s exacerbated by deep breathing, coughing, sneezing or laughing.
This type of pain is localised and easily be pinpointed.
Pleuritic chest pain is caused by inflammation of the parietal pleura.
Which conditions can mimic pleuritic pain?
Conditions such as pericarditis and MSK disorders of chest wall can mimic ‘pleuritic’ pain
How might chest pain caused by pericarditis present?
• Present with retrosternal chest pain
– Sharp, localised to front of chest
– Aggravated with inspiration, cough, lying flat
– Eased with sitting up and leaning forward
– Pericardial rub may be heard on auscultation
In which group of people are periciarditis more common in?
More common in men and adults
How might pericarditis show on an ECG?
Widespread, saddle shaped ST elevation
Why are cardiac chest pains less well localised?
Ischaemia due to coronary artery disease causes chest pain that is usually central but less well localised and may radiate to arms, neck or jaw. Visceral afferent fibres of the heart respond to ischaemia. These fibres travel to the spinal cord with autonomic nerves. There is a mixing of visceral afferents in the spinal cord resulting in less well localised pain.
Outline the pathophysiology of ischaemic heart disease
- Formation of an atherosclerotic plaque with a fibrous external cap and lipid laden core in coronary arteries(over time)
- Reduction in lumen of coronary arteries meaning less blood getting to cardiac tissues and thus they receive less oxygen
- Oxygen is needed for ATP production via aerobic respiration in myocardium
- This is imperative for cardiac function
What are the modifiable risk factors for ischaemic heart disease?
Same as risk factors for atherosclerosis: • Smoking • Hypertension • Dyslipidaemia • Diabetes • Obesity • Sedentary lifestyle
What are the non-modifiable risk factors for ischaemic heart disease?
Same as risk factors for atherosclerosis:
• Advanced age
• Family history (of early IHD)
• Male
What is stable angina?
Stable Angina is ischaemic pain which is experienced during exertion and resolves with rest. It occurs when the metabolic demands of the cardiac tissue exceeds the delivery of oxygen by the coronary arteries.
- no autonomic symptoms (sweating, vomiting)
- atherosclerotic plaque is stable
What causes relief in stable angina?
- Relief on rest
- also relief with Glyceryl trinitrate (GTN) spray
What is acute coronary syndrome?
(a spectrum of occlusion following an acute plaque
rupture)
Acute myocardial ischaemia caused by atherosclerotic coronary artery disease
– Atheromatous plaque rupture with platelet aggregation and thrombus formation
– causing an acute increased occlusion (in an already partially occluded lumen)
– Leading to ischaemia…
– and potentially infarction (myocardial tissue necrosis)
What are the 3 types of acute coronary syndrome?
- STEMI
- NSTEMI
- Unstable Angina
What is the difference between unstable angina and MI?
In unstable angina there is less ischaemia due to less occlusion of the arteries therefore there is no myocyte death - No cardiac enzyme leak
In MI there is more occlusion leading to tissue death -Cardiac enzymes leak from necrosed cardiac muscle cells
What are the features of unstable angina?
Similar to stable angina
EXCEPT
• Pain occurs at rest (or deteriorating symptom control)
• Pain may be more intense
• Pain may last longer
• Risk of deteriorating further → myocardial infarction
What are the features of an MI that are not present in angina?
Autonomic symptoms:
- sweating
- nausea
- vomiting
- pallor
What would you look for in an ECG in acute coronary syndrome?
- ST segments (elevation/depression)
- T wave inversion
- +/- pathological Q waves
What would an ECG of unstable angina show?
ST depression
T wave inversion
What would the blood tests of unstable angina show?
Troponin negative as no necrosis of cardiac tissue
What would an ECG of a NSTEMI show?
ST depression
T wave inversion
How would you differentiate between unstable angina and NSTEMI
Blood test
- troponin negative for unstable angina
- troponin positive for NSTEMI as necrosis of cardiac tissue
What would an ECG of a STEMI show?
- ST segment elevation
- Hyperacute T waves
What do you do if an ECG shows ST elevation
Don’t need to wait for blood tests - need to get them to CATH lab immediately to open up coronary artery
What is the difference between STEMI and NSTEMI?
ST elevation with STEMI occurs when the full thickness of the myocardial wall is affected, whereas an NSTEMI is due to damage limited to the subendocardial tissue
