Acute Central Chest Pain Flashcards
1
Q
What are the common causes of acute central chest pain?
A
Chest pain either benign or serious, cardiac or non cardiac causes:
Common:
ACS - unstable angina, NSTEMI, STEMI
Stable Angina (ANGINA PECTORIS)
acute pericarditis (inflammation of pericardium)
Pneumonia
Viral pleuritis
Costochondritis
GORD
Anxiety or panic disorder
2
Q
What are the less common causes of acute central chest pain?
A
- Lungs:
- PE
- Pneumothorax
- Pulmonary hypertension
- Heart:
- Pericarditis
- cardiac tamponade
- mitral valve prolapse
- Aortic –> dissection or prolapse
- GI:
- peptic ulcer
- oesophageal spasm
- acute pancreatitis
- acute cholecystitis
- gastritis
- Viral:
- herpes zoster
3
Q
Demographics and risk factors for ACS?
A
- Smoking
- Age –> men > 45 yrs, women > 55 yrs
- family history of coronary artery disease
- male sex
- hypertension
- hyperlipidaemia
- diabetes
- stroke
- peripheral arterial disease
- inactivity and obesity
- illicit drug use
- Be aware in women and older people > 75 yrs, or diabetics they may present with atypical sx such as nausea or dysponea.
4
Q
What are the risk factors for pericarditis?
A
- More common in adults 20- 50 yrs
- more common in men
- Post MI - early due to local inflammation at epicardial border, later (1 wk - months = Dressler’s syndrome)
- Autoimmune disease- rheumatoid arthritis or lupus
- bacterial/ fungal/ viral infection - viral most common
- trauma or injury
- kidney failure - uraemic pericarditis or dialysis associated pericarditis
5
Q
Risk factors for pneumonia?
A
- Children < 2 yrs
- adults > 65 yrs
- hospitalisation
- chronic disease - e.g. asthma, copd, heart disease
- smoking
- weakened immune sx –> chemo/radiotherapy, organ transplant, long term steroids, HIV/AIDS
6
Q
viral pleuritis RF
A
Cocksackie B viral infection
7
Q
Risk factors for costochondritis
A
- microtrauma - recent history of coughing or unaccostomed repetitive upper limb movement
- women
- over 40 yrs
- hispanic
8
Q
RF for GORD
A
- Fam hx of heartburn/ GORD
- older age
- hiatus hernia
- obesity
- LOS tone reducing drugs –> calcium channel blockers, alpha/beta adrenergic agonists, thephylline, anticholinergics
- stress
- NSAIDS
- smoking
- alcohol
- asthma
9
Q
RF for generalised anxiety
A
- Fam hx
- Physical/ emotional stress
- hx of physical/ sexual/ emotional trauma
- other mental health disorders - particularly panic disorder, social phobia, specific phobia
- chronic health condition
- female
10
Q
Focused history of acute central chest pain:
A
SOCRATES
- Site –> central chest?
- Onset –> duration of pain (differentiate between stable angina vs acute coronary syndrome), did it happen suddenly or build gradually? what were they doing at the time? (Exertion vs rest)
-
Character –> Aching or crushing = ACS
- Sharp pain worse on inspiration = pleuritic –> think PE/ Pneumothorax
-
Radiation
- left arm and jaw –> typical of ACS
- radiation through to the back –> aortic dissection
-
Associated symptoms:
- Dysponea –> exertiona// orthopnea/ paroxysmal nocturnal dysponea
- sweating/ claminess/ nausea –> ACS
- cough? –> duration, sputum (Pneumonia), haemopytsis (PE)
- palpitations? –> tap out rhythm
- syncope/ dizzy –> postural/ exertional/ random
- oedema –> peripheral oedema (lower limbs)
- fever –> pericarditis/ costochondritis/ pneumonia
- Time –> duration (min/ hrs/ days/ wks) and is it worsening/ fluctuating?
-
Exacerbating / relieving factors?
- inspiration worsens pain = PE/pneumothorax/pneumonia
- Exertion = ACS/PE/Pneumothorax/pneumonia
- Lying flat = pericarditis, better leaning forward
- GTN spray betters = ACS or oesophageal spasm
- Severity –> 0-10 scale
Systems review:
CV - chest pain/ palpitations/ dysponea/ syncope / orthopnea / peripheral oedema
Respiratory - dysponea / cough/ sputum/ wheeze/ haemoptysis
GI - nausea/ vomiting/ indigestion/ dysphagia/ weight loss/ abdo pain / bowel habit
CNS - headache/ vision/ motor or sensory disturbance/ loss of conciousness
PMH –>
- Heart:
- Angina/ MI/ grafts or stents
- HTN
- Hyperlipidaemia
- Aortic aneurysm/ dissection
- Respiratory -> pneumonia/ pneumothorax/PE
- GI disease –> GORD/ oeosphageal spasm
Drug hx:
- Antiplatelets or anticoagulants
- GTN
- contraceptive pill –> increased risk thromboembolic disease
- OTC/ allergies
Social hx:
- Smoking
- alcohol
- recreational drugs - cocaine and coronary artery vasospasm
- diet - obesity/ fat/ salt intake
- exercise
- Living situation/ ADL
ICE
11
Q
Differentials: Signs and symptoms
How can pain present differently?
what pain presentations are typical for which conditions?
A
- Constricting pain –> cardiac ischaemia or oesophageal spasm
- pain lasting over 15 mins and dull, central, and crushing –> ACS
- sharp pleuritic pain, catches on inspiration –> originates from pleura or pericardium –> pneumonia, pulmonary embolus or pericarditis
- sudden, substernal tearing pain radiating towards the back – > aortic dissection
- Precipitating factors:
- Cardiac pain more likely with exercise or emotion, typically relieved with rest or nitrates
- pain following fodd, lying down, alcohol or relieved by antacids –> GI cause
- heartburn and acid regurg –> typical of GORD
- referred pain from abdominal pathology (e.g. acute cholecystitis and pancreatitis) will have associated symptoms
- e.g. acute cholecystitis –> fever/ nausea/ vomiting/ severe upper R quadrant pain/ jaundice
- acute pancreatits –> sudden onset, constant, radiation to back, worsen with movement, vomiting
12
Q
Differentials: Signs and symptoms
What are some atypical symptoms and typical symptoms for ACS?
A
- Typical: (along with central crushing pain that may radiate to jaw/ left arm)
- dysponea
- nausea and vomiting
- sweating
- Atypical:
- syncope
- nausea/ vomiting or dysponea in abscence of chest pain
- more common in women/ diabetics/ over 75 yrs
13
Q
Differentials: Signs and symptoms
What can associated dysponea with chest pain allude to?
A
Dysponea –> cardiac ischaemia, pulmonary embolism, pneumothorax, pneumonia
14
Q
Key features on clinical examination:
General features in cardiac exam
A
- Clubbing = congenital cyanotic disease (tetralogy of fallot), subacute infective endocarditis
- splinter haemorrhages = infective endocarditis
- peripheral cyanosis = cold hands and feet, occurs when there is peripheral vasoconstriction and blood stasis in extremities. Congestive heart failure, circulatory shock, raynauds
- central cyanosis =shunting of deoxygenated blood into systemic circulation e.g R- L shunt
- Also think, oedema, jaundice, pallor of mucous membrane cachexia and obesity
15
Q
Key features on clinical examination:
Rate and rhythm
A
Pulse: Rate and Rhythm
- 60- 100 bpm
- rhythm should be regular
- premature beats - occasional or repeated irregularities superimposed on regular rhythm or intermittent heart block as dropped beats
- atrial fibrillation - irregularly irregular pulse that persists with exercise (pulse irregularity due to ectopic beats usually disappears on exercise)
16
Q
Key features on clinical examination:
Pulse variations and clinical indication
A
- Carotid pulsation –> not normally visible but may be in high output conditions (e.g. fever/ anaemia/ thyrotoxicosis) and in aortic regurgitation
- collapsing/ water hammer pulse –> large volume pulse of short duration with a brisk rise and fall. Aortic valvular regurgation or persistent ductus arteriosus.
- Small volume pulse –> cardiac failure, shock, obstructive valvular or vascular disease or tachyarrhythmias
- Plateau pulse –> small in volume and slow in rising to a peak. Aortic stenosis.
- Alternating pulse –> alternate pulse weak followed by strong –> severe myocardial failure and indicates poor prognosis.
- Bigeminal pulse --> caused by ectopic beat after sinus beat, irregular rhythm with weaker pulse after first pulse caused by sinus beat.
- Pulsus bisferiens –> double pulse, first pulse caused by left ventricular contraction in systole (called percussion wave), second caused by a delayed recoil of the vascular bed as left ventricle empties slowly or is obstructed (tidal wave). Found in hypertrophic cardiomyopathy or mixed aortic valve disease.
- Dicrotic pulse –> accentuated dicrotic notch found in sepsis, hypovolaemic shock or aortic valve replacement.
26
Q
Examination signs: Costochondritis
A
- Reproducible pain on chest wall palpation especially at costochondral junctions (junction between costal cartilage and rib bone)
27
Q
Examination signs: Herpes zoster
A
Tenderness unilaterally in a dermatomal distribution - with or without typical rash indicates herpes zoster (pain presents 2-3 days prior to rash)
Rash is vesicular on an erythematous base in unilateral distribution of one dermatome.
29
Q
What further investigations would be done if suspecting:
Angina pectoris 1st line
A
- Resting ECG - often normal in stable angina, but ST depressions may indicate ischaemia or Q waves indicative of prior infarction
- FBC - anaemia leads to additional cardiac workload and reduced O2 delivery to myocardiu, which exacerbates angina
- Fasting lipid profile - hyerplipidaemia associated with Ischaemic heart disease - elevated LDL = higher risk, elevated HDL = protective
- HbA1c or fasting blood glucose - hyperglycaemia linked to ischaemic heart disease
31
Q
What investigations if suspecting:
ACS (STEMI/ NSTEMI/ Unstable Angina)
A
-
ECG
- ST elevation MI (STEMI) - ST elevation > 1mm in 2 anatomically adjacent leads or new left bundle branch block
- NSTEMI or unstable angina –> ST segment depression or T wave inversion
- Trial sublingual glyceryl trinitrate - also control pain
-
CXR
- normal or signs of heart failure e.g. increased alveolar markings
- blood diversion to upper lobes
- cardiomegaly
- pleural effusion
- kerley B lines (septal lines) - interlobular septa become prominent due to oedema in the connective tissue inbetween lung lobes. Kerley B - often 1 - 2 cm in periphery of lung, extend out to pleural lining.
-
Cardiac Enzymes (troponin and creatinine kinase MB)
- elevated in STEMI and NSTEMI
- Troponin released into blood 3-4 hours after MI, peaks 24 hrs, remains detectable for 10- 14 days
- Troponin more specific but less useful to detect reinfarction
- Creatinine kinase - rises 3/4 hrs after MI, remains elevated 3-4 days- useful to detect reinfarction
- FBC -> thrombocytopenia to estimate risk of bleeding
- U and E’s –> Urea and creatinine to monitor kidney function, electrolytes to monitor risk of cardiac arrhythmia
- LFT –> useful if considering tx with drugs that undergo hepatic metabolism
-
Other investigations:
- B type natriuretic peptide (BNP and NT-proBNP) - released during ischaemia, helps to risk stratify.
- Coronary angiography - STEMI - critical occlusion of coronary artery, NSTEMI and unstable angina - evidence of coronary artery narrowing. STEMI- urgent coronary angiography with reperfusion. NSTEMI/UnstableA - if high risk features (ongoing chest pain, ECG changes, elevated cardiac enzymes).
32
Q
What investigations if suspecting:
Acute pericarditis
A
- ECG - upwards concave ST segment elevation with PR depressions (60% patients).
- Serum troponin - if raised suggests myocardial involvement and coincides with magnitude of ST segment elevation. Usually midly elevated, can be in range of acute MI.
- pericardial fluid/ blood culture –> purulent pericarditis is lifethreatening requires immediate confirmation via urgent pericardiocentesis. Pericardial fluid should be tested for bacterial/ fungal/ TB causes. Blood culture too.
- ESR - elevated consistent with inflammatory state
- CRP - elevated consistent with inflammatory stat
- Urea - elevated suggests uraemic cause- elevated above 21.4 mmol/L or 60 mg/dL suggests renal failure
- FBC - Leukocytosis - infectious cause
- CXR - usually normal unless large pericardial effusion - cardiothoracic ratio will be raised. Also looking for lung pathology.
- Echocardiography –> indicated when cardiac tamponade is suspected and differentiates from ACS. Looking to image pericardial effusion.
- can do Chest CT/ cardiac MRI –> echocardiogram inconclusive this can also detect pericardial effusion
