9. Chest Pain

Question 1

List the differential diagnoses of chest pain.

Answer 1

Musculoskeletal inflammation 
Acute coronary syndrome 
Pulmonary embolism 
Stable angina 
Pleurisy
Oesophagitis 
Pneumothorax
Peptic ulcer disease 
Myopericarditis 
Aortic dissection 
Boerhaave’s perforation

Question 2

List three differentials for chest pain that are more likely in young patients?

Answer 2

PE
Pneumothorax
Cocaine-induced coronary artery spasm

Question 3

What are the five fatal causes of chest pain that you must rule out when taking a history?

Answer 3

PE 
Pneumothorax 
ACS 
Aortic dissection 
Boerhaave’s perforation

Question 4

Which signs on examination could suggest that the patient has significant risk factors of cardiovascular disease?

Answer 4

Signs of hypercholesterolaemia – e.g. xanthelasma, xanthomata, corneal arcus
Signs of peripheral vascular disease – e.g. weak pulses, peripheral cyanosis, cool peripheries, atrophic skin, ulcers, bruits

Question 5

Describe the pain experienced during an aortic dissection.

Answer 5

Sudden-onset, intense tearing chest pain

Radiating to the back (between the shoulder blades)

Question 6

List some clinical signs that are associated with aortic dissection.

Answer 6

Different blood pressures in the two arms
Aortic regurgitation
Pleural effusion (due to irritation of pleura)

Question 7

Describe the typical presentation of pneumothorax.

Answer 7

Sudden-onset pleuritic chest pain with breathlessness

Question 8

Describe the typical presentation of PE.

Answer 8

Sudden-onset pleuritic chest pain with breathlessness
With or without haemoptysis
Patients may also have a swollen/inflamed leg (DVT)

Question 9

What is the most common finding on examination of patients with PE?

Answer 9

Tachycardia

Question 10

Describe the typical presentation of Boerhaave’s perforation.

Answer 10

Sudden-onset severe chest pain immediately after an episode of vomiting

Question 11

What is the most important investigation to perform in a patient with chest pain?

Answer 11

ECG

Question 12

Other than tachycardia, which other ECG sign is associated with PE?

Answer 12

S1Q3T3

Question 13

What are the two main ECG signs associated with myocardial infarction?

Answer 13

ST elevation

New-onset LBBB

Question 14

How long is the delay between myocardial damage and a rise in troponins?

Answer 14

3 hours

Question 15

Describe how CK-MB is different to troponins.

Answer 15

They rise more rapidly following damage to the myocardium but it is less specific for cardiac damage
Returns to normal after 2-3 days

Question 16

How long does it take for troponins to fall back to normal?

Answer 16

7+ days

Question 17

Other than ACS, what else can cause a rise in serum troponins?

Answer 17

Coronary artery spasm 
Aortic dissection
Myopericarditis 
Hypertrophic cardiomyopathy
Severe heart failure 
PE

Question 18

Why is it important to consider the patient’s renal function when interpreting troponin results?

Answer 18

Troponins are renally excreted – so a raised troponin in the context of renal failure may NOT be significant

Question 19

Why might you measure blood glucose levels in a patient with a suspected ACS?

Answer 19

Diabetic patients can have ‘silent infarcts’ – MI without chest pain

Question 20

Which form of imaging may be used to investigate a patient presenting with chest pain? Describe some pathological signs that you might see.

Answer 20

Erect CXR
Allows exclusion of pneumothorax, aortic pathology (e.g. widened mediastinum due to dissection) and boerhaave’s perforation (would cause pneumomediastinum, pleural effusion or pneumothorax)

Question 21

Describe the ECG pattern of a posterior myocardial infarct.

Answer 21

ST depression in the anterior leads (V1-4)

Question 22

Describe the management of ACS.

MONABASH

Answer 22

Morphine – may be given with an anti-emetic e.g. metoclopramide
Oxygen – maintain oxygen saturations of 94%
Nitrates – e.g. GTN or imdur
Anticoagulants – e.g. aspirin + clopidogrel
Beta-blockers – reduce myocardial oxygen demand
ACE inhibitors – reduce adverse cardiac remodeling + antihypertensive
Statins – control cholesterol
Heparin – can be used to reduce future thromboembolic risk

Question 23

When are beta-blocker contraindicated?

Answer 23

Heart block
Asthma
Acute heart failure

Question 24

What is the first-line treatment option for STEMI?

Answer 24

Percutaneous coronary intervention (GOLD STANDARD)
Thrombolysis
NOTE: this should be done within 12 hours of onset of pain (ideally within 1 hour)

Question 25

Describe how NSTEMI patients should be managed.

Answer 25

If haemodynamically unstable – immediate angioplasty

Other NSTEMI patients should be risk stratified – high risk patients should receive angioplasty

Question 26

Which scoring system allows risk stratification of NSTEMI patients.

Answer 26

GRACE score

Question 27

Describe some lifestyle advice that should be given to a patient who has recently suffered an ACS.

Answer 27

Stop smoking
Reduce salt intake
Exercise
Weight loss

Question 28

What are the different treatment options used to control blood pressure in patients at risk of a cardiovascular event?

Answer 28

ACE inhibitors - < 55 yo or white

CCBs or thiazide diuretics - > 55 yo or non-white

Question 29

Which drugs may be used to reduce the thromboembolic risk in patients at risk of a cardiovascular event?

Answer 29

Aspirin

ADP-receptor antagonists (e.g. clopidogrel and prasugrel)

Question 30

What treatment may be considered in patients with severe ventricular dysfunction and conduction block?

Answer 30

Implantable cardioverter defibrillator (ICD)

Question 31

List some complications of MI.

DARTH VADER

Answer 31

Death
Arrhythmia 
Rupture 
Tamponade 
Heart failure 
Valvular disease 
Aneurysm
Dressler’s syndrome 
Embolism 
Reinfarction

Question 32

What is Dressler’s syndrome?

Answer 32

Autoimmune pericarditis that occurs 2-10 weeks after MI

NOTE: this is different from simple post-MI pericarditis (2-4 days after MI)

Question 33

Describe the treatment of Dressler’s syndrome.

Answer 33

Analgesia
Anti-inflammatories
Pericardial effusion may need pericardiocentesis

Question 34

List some rare causes of angina type symptoms.

Answer 34

Prinzmetal angina – angina at rest that occurs in cycles and is caused by vasospasm of the coronary arteries
Coronary syndrome X – signs associated with decreased blood flow to the heart tissue but with normal coronary arteries

Question 35

Describe the Stanford criteria for aortic dissection and how this classification influences treatment choice.

Answer 35

Type A – ascending aorta – SURGICAL EMERGENCY

Type B – descending aorta – managed medically

Question 36

What is Boerhaave’s perforation?

Answer 36

Perforation of the oesophagus due to forceful vomiting

Question 37

Which other cause of chest pain is associated with nausea and vomiting?

Answer 37

Inferior MI
NOTE: this can be differentiated from Boerhaave’s perforation because in Boerhaave’s, the vomiting precedes the chest pain whereas with inferior MI the chest pain comes first

Question 38

What are patients with Boerhaave’s perforation prone to developing?

Answer 38

Pleural effusion
Pneumomediastinum
Pneumothorax