Blackboard Chest Pain EMQs Flashcards

1
Q

A 73 year old banker complains of chest pressure which comes on predictably on exertion. It is relieved when he sits down and rests.

What is the diagnosis?

  1. Variant angina
  2. Unstable angina
  3. MI
  4. GORD
  5. Syndrome X
  6. Decubitus angina
  7. Pericarditis
  8. Aortic dissection
  9. PE
  10. Pneumothorax
  11. Herpes-Zoster virus
  12. Anxiety disorder
  13. Stable angina
A
  1. Stable angina

This patient has presented with stable angina. Resting ECG is often normal and the patient is asymptomatic. However during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia and the patient will complain of chest pain. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

A 55 year old man is admitted to A&E with chest pain which is central in origin and came on while he was waiting for his bus. Troponin and CK-MB are not elevated.

What is the diagnosis?

  1. Variant angina
  2. Unstable angina
  3. MI
  4. GORD
  5. Syndrome X
  6. Decubitus angina
  7. Pericarditis
  8. Aortic dissection
  9. PE
  10. Pneumothorax
  11. Herpes-Zoster virus
  12. Anxiety disorder
  13. Stable angina
A
  1. Unstable angina

This is UA characterised by chest pain at rest. ECG will typically show ST depression and T wave inversion. Acute management includes antiplatelets and antithrombotics to reduce damage and complications. Long term management aims at reducing risk factors. Key risk factors include obesity, hypertension, smoking, hyperlipidaemia, FH, DM and positive FH. People with diabetes may again present with atypical symptoms. Cardiac biomarkers will not be elevated although in a patient who has had an acute MI days earlier, troponin may remain elevated (remains elevated up to 10-14 days after release). All patients with presumed cardiac chest pain should in the first instance get oxygen, morphine and GTN with antiplatelet therapy in the absence of contraindications.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

A 59 year old woman complains of chest pain. ECG shows ST segment depression. However, a subsequent coronary angiogram is normal.

What is the diagnosis?

  1. Variant angina
  2. Unstable angina
  3. MI
  4. GORD
  5. Syndrome X
  6. Decubitus angina
  7. Pericarditis
  8. Aortic dissection
  9. PE
  10. Pneumothorax
  11. Herpes-Zoster virus
  12. Anxiety disorder
  13. Stable angina
A
  1. Syndrome X

This is cardiac syndrome X, not to be confused with the metabolic syndrome. Here, there is chest pain with usual ST segment changes associated with coronary artery disease but with normal coronary arteries. It is treated with calcium channel blockers such as nifedipine.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

A 57 year old female complains of chest pain which occurs at rest. ECG performed on A&E admission shows ST elevation but a subsequent angiogram with a provocative agent shows an exaggerated spasm of the coronary arteries.

What is the diagnosis?

  1. Variant angina
  2. Unstable angina
  3. MI
  4. GORD
  5. Syndrome X
  6. Decubitus angina
  7. Pericarditis
  8. Aortic dissection
  9. PE
  10. Pneumothorax
  11. Herpes-Zoster virus
  12. Anxiety disorder
  13. Stable angina
A
  1. Variant angina

Variant angina (Prinzmetal) is angina caused by coronary artery vasospasm rather than atherosclerosis. It occurs at rest and in cycles. Many patients will also have some degree of atherosclerosis although not in proportion to the severity of the chest pain experienced. ECG changes are of ST elevation (rather than depression) when the patient is experiencing an attack and a stress ECG will be negative. Patients with Prinzmetal angina are often treated for ACS and indeed, cardiac biomarkers may be raised as vasospasm can cause damage to the myocardium. The gold standard investigation is with coronary angiography and the injection of agents to try to provoke a spasm.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

A 44 year old female complains of a two week history of tight chest pain which occurs when he is lying down.

What is the diagnosis?

  1. Variant angina
  2. Unstable angina
  3. MI
  4. GORD
  5. Syndrome X
  6. Decubitus angina
  7. Pericarditis
  8. Aortic dissection
  9. PE
  10. Pneumothorax
  11. Herpes-Zoster virus
  12. Anxiety disorder
  13. Stable angina
A
  1. Decubitus angina

This patient has chest pain which occurs on lying down, which is decubitus angina by definition.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

An overweight 63 year old male with a history of hypertension presents with cardiac sounding chest pain while watching TV. However, his cardiac biomarkers are not elevated. An ECG is ordered which shows ST depression and T wave inversion.

What is the diagnosis?

  1. Variant angina
  2. Unstable angina
  3. MI
  4. GORD
  5. Syndrome X
  6. Decubitus angina
  7. Pericarditis
  8. Aortic dissection
  9. PE
  10. Pneumothorax
  11. Herpes-Zoster virus
  12. Anxiety disorder
  13. Stable angina
A
  1. Unstable angina
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

This drug lowers heart rate, cardiac output and mean arterial blood pressure during exercise. It can also be used for migraine prophylaxis and glaucoma. This drug also causes a decrease in endogenous renin release.

Name the drug

  1. Alpha-1 agonist
  2. Alpha-2 agonist
  3. Beta-1 agonist
  4. Beta-2 agonist
  5. Adrenaline
  6. Beta blocker
  7. Calcium channel blocker
  8. ACEi
  9. Spironolactone
  10. GTN
  11. Loop diuretics
  12. Thiazide diuretics
A
  1. Beta blocker

Beta blockers lower heart rate, CO and MABP during exercise. They indeed also act to reduce renin release as well as the release of NA. Their use ranges from migraine prophylaxis, anxiety and hypertension to thyrotoxicosis, post-MI and chronic heart failure. They are also useful in arrhythmias where they act to increase the refractory period of the AVN.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

This drug is a vasoconstrictor which can be used as a nasal decongestant. It is also mydriatic when used as an eye drop.

Name the drug

  1. Alpha-1 agonist
  2. Alpha-2 agonist
  3. Beta-1 agonist
  4. Beta-2 agonist
  5. Adrenaline
  6. Beta blocker
  7. Calcium channel blocker
  8. ACEi
  9. Spironolactone
  10. GTN
  11. Loop diuretics
  12. Thiazide diuretics
A
  1. Alpha-1 agonist

Alpha 1 agonists such as phenylephrine are vasoconstrictors and also have a use as a mydriatic. They are used as nasal decongestants as a result of their vasoconstrictor effect.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

This drug leads to the release of NO to reduce venous return to the heart. Chronic use can lead to tolerance.

Name the drug

  1. Alpha-1 agonist
  2. Alpha-2 agonist
  3. Beta-1 agonist
  4. Beta-2 agonist
  5. Adrenaline
  6. Beta blocker
  7. Calcium channel blocker
  8. ACEi
  9. Spironolactone
  10. GTN
  11. Loop diuretics
  12. Thiazide diuretics
A
  1. GTN

GTN is glyceryl trinitrate, which leads to NO release. This causes vasodilation and a reduction in venous return to the heart, which decreases cardiac work load. This reduces preload (ventricular return) and afterload (peripheral vascular resistance). It is also weakly antiplatelet and has a weak direct action to vasodilate the coronary arteries. It is often also used sublingually for rapid relief of angina. Chronic use can indeed lead to tolerance and as such an eccentric regime is recommended.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

This drug leads to arterial vasodilation by action on vascular smooth muscle cells. It can lead to unwanted ankle oedema, headache, hypotension and palpitations.

Name the drug

  1. Alpha-1 agonist
  2. Alpha-2 agonist
  3. Beta-1 agonist
  4. Beta-2 agonist
  5. Adrenaline
  6. Beta blocker
  7. Calcium channel blocker
  8. ACEi
  9. Spironolactone
  10. GTN
  11. Loop diuretics
  12. Thiazide diuretics
A
  1. Calcium channel blocker

This describes the action of a non-rate slowing dihydropyridine calcium channel blocker such as amlodipine. These act by inhibiting the opening of L-type calcium channels, inhibiting entry of calcium ions into VSMCs. This causes arterial vasodilation. These drugs are used for hypertension and angina and unwanted effects include those listed. The palpitations a patient may experience are due to reflex tachycardia from arterial vasodilation. Note also that rate-slowing calcium channel blockers also exist such as verapamil and diltiazem and uses for these also include arrhythmias such as paroxysmal SVT and AF.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

A 72 year old male, in hospital post MI complains of dyspnoea and collapse four days later. He appears pale and his right leg is swollen compared to the left. Apex not displaced. No mumurs. Pulse 128 BP 100/55 temp37. JVP elevated. Bibasal crackles.

What is the diagnosis?
A.	DVT
B.	Ventricular tachycardia
C.	Pericarditis
D.	Papillary muscle rupture
E.	Unstable angina
F.	Tamponade
G.	Atrial Fibrillation
H.	Pulmonary oedema
I.	Pulmonary Embolus
J.	Angina
A

I. Pulmonary embolus

Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Tachycardia is commonly seen. Raised JVP is a feature here which is elicited if cor pulmonale is present. This patient has DVT which is a strong PE risk factor. Recent acute MI is also a weak risk here. Other strong risk factors include obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

A 62 year old woman becomes unwell and dyspnoeic three days after an acute myocardial infarction. Apex 6th ICS mid axillary line, pansystolic murmur radiating to the axilla. Crackles bibasal to mid zones. JVP elevated, ankles swollen. Pulse 126, BP 105/65, RR 24

What is the diagnosis?
A.	DVT
B.	Ventricular tachycardia
C.	Pericarditis
D.	Papillary muscle rupture
E.	Unstable angina
F.	Tamponade
G.	Atrial Fibrillation
H.	Pulmonary oedema
I.	Pulmonary Embolus
J.	Angina
A

D. Papillary muscle rupture

Inferior MI can cause rupture of the posteromedial papillary muscle while anterolateral infarctions can cause rupture of the anterolateral papillary muscle. This has led to acute mitral regurgitation (RV papillary rupture is rare but can cause regurgitation of the tricuspid valve). Complete rupture of the papillary muscle is fatal and causes wide-open MR. Those with incomplete rupture need emergency cardiac surgery with inotropic support considered for transient stabilisation prior to this. The pansystolic murmur which radiates into the axilla is a sign of mitral regurgitation here. This has resulted in SOB and tachycardia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

A 50 year old male, has an anterior infarct but is thrombolysed within 3 hours. Three days later the patient developed sudden intermittent chest discomfort on mobilizing. Chest was clear. Heart sounds were normal. ECG shows ST elevation in leads II, III, aVF, AVL, and V1 to V6. pulse 90 , BP 125/90

What is the diagnosis?
A.	DVT
B.	Ventricular tachycardia
C.	Pericarditis
D.	Papillary muscle rupture
E.	Unstable angina
F.	Tamponade
G.	Atrial Fibrillation
H.	Pulmonary oedema
I.	Pulmonary Embolus
J.	Angina
A

C. Pericarditis

This patient has presented with pericarditis. Symptoms include a sharp and severe chest pain retrosternally which is worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’ (although this is not present most of the time). There may be diffuse ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. The prior viral infection is a risk factor with the most common pericardial infection being viral. Bacterial purulent pericarditis also occurs. The inflammation is due either to direct viral attack or immune mediated damage. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

A 79 year old male with long standing angina presented to A and E with an anteroseptal MI. He became unrousable, HS were normal but pulse rate was 200 and regular BP 60/0 RR24

What is the diagnosis?
A.	DVT
B.	Ventricular tachycardia
C.	Pericarditis
D.	Papillary muscle rupture
E.	Unstable angina
F.	Tamponade
G.	Atrial Fibrillation
H.	Pulmonary oedema
I.	Pulmonary Embolus
J.	Angina
A

B. Ventricular tachycardia

VT and VF can occur during ischaemia and reperfusion and can be fatal. They can also occur at any stage after an MI due to re-entry circuits at the border between myocardial scar tissue and normal myocardium. They are commonly seen in patients who have a decreased ejection fraction. Appropriate treatment should be initiated with DC cardioversion and anti-arrhythmics. Electrolytes should also be optimised (especially potassium and magnesium levels) as electrolyte imbalances present an added risk of ventricular arrhythmias. Medical management afterwards is essential, especially with beta blockers which decrases incidence of ventricular events. Those with persistently low LV ejection fraction which is unresponsive should be considered for an implantable caridioverter defibrillator.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

An 80 year old male with an anterior MI, initially improved, but then started deteriorating. Became very unwell, pale, no murmur, crackles at both lung bases, ankles swelling JVP increased, apex 6th ICS pulse 115 BP 125/88 RR 25

What is the diagnosis?
A.	DVT
B.	Ventricular tachycardia
C.	Pericarditis
D.	Papillary muscle rupture
E.	Unstable angina
F.	Tamponade
G.	Atrial Fibrillation
H.	Pulmonary oedema
I.	Pulmonary Embolus
J.	Angina
A

H. Pulmonary oedema

This patient has developed congestive heart failure as a complication of his MI. This is caused by decreased left ventricular function occuring after MI due to myocardial damage, infarct progression and remodelling of the LV tissue after the injury. Displaced apex beat is commonly found along with the other mentioned features in this history. Tests such as ECG, CXR, BNP (B-type natriuretic peptide) and echocardiogram will help confirm this diagnosis. CXR here is likely to confirm pulmonary congestion and may also show cardiomegaly. Initial symptomatic relief will involve diuretics and oxygen primarily, with the patient being sat upright. Treatment will also involve medication including beta blockers and ACE inhibitors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

A 55 year old obese female complains of an occasional burning pain behind the sternum. The pain is worse after large meals and when drinking hot liquids.

What is the diagnosis?
A.	Costochondritis
B.	Pulmonary Embolism
C.	Pericarditis
D.	Pneumothorax
E.	Angina
F.	Peptic ulcer disease
G.	GORD
H.	Aortic dissection
I.	Pneumonia
J.	MI
K.	Rib fracture
A

G. GORD

This patient has GORD characterised by heartburn and regurgitation of acid. It is more severe at night when the patient is lying flat and also when the patient is bending over. Risk factors include obesity and hiatus hernia. Diagnosis is generally clinical and can also be achieved by a diagnostic trial of a PPI. Normally an upper GI endoscopy is reserved for complications such as strictures, Barrett’s or cancer, or for atypical features. An OGD may show oesophagitis or Barrett’s (red velvety), however OGD may be normal. Manometry and pH monitoring may also be performed, but in this case, this patient will probably just have a therapeutic and diagnostic trial of a PPI instead of an OGD.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

A 50 year old female presents with a sharp chest pain which is worse on inspiration. Her temperature is 38oC and she has a history of a recent viral infection. Her pulse is much weaker on inspiration and her JVP is raised.

What is the diagnosis?
A.	Costochondritis
B.	Pulmonary Embolism
C.	Pericarditis
D.	Pneumothorax
E.	Angina
F.	Peptic ulcer disease
G.	GORD
H.	Aortic dissection
I.	Pneumonia
J.	MI
K.	Rib fracture
A

C. Pericarditis

This patient has presented with pericarditis. Symptoms include a sharp and severe chest pain retrosternally which is worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’. There is pulsus paradoxus here too. There may be diffuse ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. The prior viral infection is a risk factor with the most common pericardial infection being viral. Bacterial purulent pericarditis also occurs. The inflammation is due either to direct viral attack or immune mediated damage. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

A 26 year old racing driver is brought to A&E from an RTA. He is dyspnoeic, has a BP of 105/60 and pulse 95bpm. O/E the trachea is deviated to the Left and there is decreased expansion of the left side relative to the right.

What is the diagnosis?
A.	Costochondritis
B.	Pulmonary Embolism
C.	Pericarditis
D.	Pneumothorax
E.	Angina
F.	Peptic ulcer disease
G.	GORD
H.	Aortic dissection
I.	Pneumonia
J.	MI
K.	Rib fracture
A

D. Pneumothorax

This patient has developed a left sided tension pneumothorax and will need emergency intervention in the form of the insertion of a large bore cannula into the 2nd intercostal space in the MCL of the affected side. This will need to be followed by the insertion of a chest drain.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

A 72 year old man with a history of hypertension, presents with sudden tearing chest pain radiating to the back. The peripheral pulses are absent and there is a widened mediastinum on CXR.

What is the diagnosis?
A.	Costochondritis
B.	Pulmonary Embolism
C.	Pericarditis
D.	Pneumothorax
E.	Angina
F.	Peptic ulcer disease
G.	GORD
H.	Aortic dissection
I.	Pneumonia
J.	MI
K.	Rib fracture
A

H. Aortic dissection

The tearing chest pain suggests aortic dissection. There may also be interscapular pain with dissection of the descending aorta. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. BP differential between the 2 arms is a hallmark feature. Pulse differences may also be present in the lower limbs. There may also be the diastolic murmur of AR in proximal dissections. CXR may show a widened mediastinum like this case, and helps to rule out pulmonary causes of pain. A CT scan is indicated as soon as a diagnosis of aortic dissection is suspected and should be from the chest to the pelvis to see the full extent of the dissecting aneurysm. What you will see is the intimal flap. MRI is more sensitive and specific but is more difficult to obtain acutely.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

A 66 year old male complains of a severe crushing pain in his chest. He is sweating, short of breath, says he feels sick and appears very drowsy. The pain is not relieved by the GTN spray he was given by his GP.

What is the diagnosis?
A.	Costochondritis
B.	Pulmonary Embolism
C.	Pericarditis
D.	Pneumothorax
E.	Angina
F.	Peptic ulcer disease
G.	GORD
H.	Aortic dissection
I.	Pneumonia
J.	MI
K.	Rib fracture
A

J. MI

This patient’s chest pain sounds like an MI. Chest pain is classically severe and heavy in nature (often described as crushing), located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are also common symptoms. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia. An ECG is indicated. STEMI, new LBBB or confirmed posterior MI is an indication for PCI/thrombolysis. It is worth noting that RV infarction is present in 40% of inferior infarcts so in this case, right sided ECG leads should also be obtained.

GTN is given in acute suspected MI (along with oxygen, aspirin and morphine). It acts to reduce myocardial oxygen demand and lessens ischaemia (and may rarely abort MI if there is coronary spasm). The fact it does not relieve the pain suggests this is not a typical episode of angina. Sublingual dosing should be given first and IV therapy is reserved for those with hypertension of heart failure. Morphine is essential to relieve pain and its related sympathetic response, which can add to myocardial oxygen demand.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Mrs E, a 26 year old American lady, arrives in A&E with severe central chest pain. She is shocked, pale and sweaty. You notice a complete set of LV luggage in her bay as you go over to examine her. An overwrought Mr E implores you to save the life of his wife and their unborn child.

What is the diagnosis?
A. Pneumothorax
B. Panic disorder
C. Tietze's syndrome
D. TIA
E. Oesophageal reflux
F. ACS
G. Coctochondritits
H. Herpes-Zoster
I. Cyclical breast pain
J. Ectopic pregnancy
K. Pulmonary embolism
L. Pleuritis
M. Fibromyalgia
A

K. Pulmonary embolism

The underlying pathophysiology of PE is based on Virchow’s triad. SOB is a common symptom and there may also be pleuritic chest pain and haemoptysis. Most patients also describe a feeling of apprehension. Pregnancy is a strong risk and there has also presumably been long-haul air travel here. Other strong risk factors include recent surgery, DVT, obesity, prolonged bed rest, malignancy, previous VTE and the thrombophilias such as factor V Leiden. The oral contraceptive pill is also associated with an increased risk of VTE but is a weak risk factor. CXR may be normal or may have findings suggestive of PE such as band atelectasis, hemidiaphragm elevation, Fleischner’s sign, Westermark’s sign and Hampton hump. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Mr L, an investment banker, who is as wide as he is tall, has been brought in to A&E at 2am on Sunday after collapsing at the kebab shop in Shepard’s Bush Road. He is dressed in a schoolboy outfit, which only makes sense when a similarly dressed friend arrives and tells you that the office went clubbing at Po Na Na together. Apparently Mr L had been complaining of tight chest pain and anxiety earlier in the evening but a cigarette calmed him down.

What is the diagnosis?
A. Pneumothorax
B. Panic disorder
C. Tietze's syndrome
D. TIA
E. Oesophageal reflux
F. ACS
G. Coctochondritits
H. Herpes-Zoster
I. Cyclical breast pain
J. Ectopic pregnancy
K. Pulmonary embolism
L. Pleuritis
M. Fibromyalgia
A

F. ACS

ACS refers to acute myocardial ischaemia caused by atherosclerotic disease and encompasses STEMI, NSTEMI and unstable angina. Once you are aware that this is what acute coronary syndrome encompasses then this diagnosis becomes obvious. This man is clearly overweight and is seen munching a kebab so there are clear cardiovascular risk factors here. The tight chest pain followed by collapse make this sound like a myocardial infarction. Those with identified STEMI should be considered for immediate reperfusion therapy by thrombolytics or percutaneous coronary intervention. Those with NSTEMI or unstable angina do not benefit from this. The pathophysiology underlying all three of these disease processes involves disruption of vulnerable or high risk plaques leading to platelet activation and thrombus formation. Blood flow is disrupted. Most complain of chest pain which is described as substernal pressure, heaviness, squeezing, burning or tightness. It may either localise or radiate to the arms, shoulders, back, neck or jaw and is usually reproduced by exertion, eating, exposure to cold or emotional stress. ECG and serum biomarkers like troponin will be useful in confirming the diagnosis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Miss A, a 52 year old, attends Rapid Diagnostic Clinic for Breast Clinic at CX. She is concerned over an area of tenderness on her left breast. O/E you find that the lower medial quadrant of the right breast feels sore when you palpate deeply. There is no palpable lump and both mammography and ultrasound are normal.

What is the diagnosis?
A. Pneumothorax
B. Panic disorder
C. Tietze's syndrome
D. TIA
E. Oesophageal reflux
F. ACS
G. Coctochondritits
H. Herpes-Zoster
I. Cyclical breast pain
J. Ectopic pregnancy
K. Pulmonary embolism
L. Pleuritis
M. Fibromyalgia
A

G. Costochondritis

This is costochondritis, or Tietze’s syndrome (which describes constochondritis accompanied by chest wall swelling), which presents with insidious onset of anterior chest wall pain which is made worse by certain movements of the chest and deep inspiration. The key sign here is that there is pain when palpating the costochondral joints, particularly the 2nd to the 5th and the diagnosis is clinical. Tests are done to exclude other diagnoses here such as breast pathology. First line treatment is with NSAIDs. Oral NSAIDs are preferred in a primary care setting and a beneficial response confirms the diagnosis. If NSAIDs or local corticosteroid injection (usually performed by a specialist) fail to make the symptoms better than you should seek further investigations and consider a wider differential diagnosis which include conditions like pleuritis, ACS, PE, rib fracture and GORD.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Mrs I, a plump 65 year old lady, presents with burning chest pain. She complains that the pain has stopped her working in her allotment, as it gets worse when she tends her marrows. She also finds it difficult to sleep and has to use at least 3 pillows.

What is the diagnosis?
A. Pneumothorax
B. Panic disorder
C. Tietze's syndrome
D. TIA
E. Oesophageal reflux
F. ACS
G. Coctochondritits
H. Herpes-Zoster
I. Cyclical breast pain
J. Ectopic pregnancy
K. Pulmonary embolism
L. Pleuritis
M. Fibromyalgia
A

E. Oesophageal reflux

This burning chest pain is comes on when this lady bends over while tending her allotment and when she lies down at night to sleep. This indicates GORD and there is heartburn here and acid regurgitation. No atypical symptoms are present in this lady but these can include cough, laryngitis, asthma or dental erosion. The diagnosis is clinical here and a therapeutic trial of PPI can both be diagnostic and serve as initial treatment. UGI endoscopy is not needed unless there are complications you want to investigate for, and for atypical, persistent or relapsing symptoms, or if there are alarm features like weight loss or anaemia that need looking into. Complications that are worrying include stricture formation, Barrett’s oesophagus (metaplasia) or oesophageal carcinoma. Upon stopping PPIs there is a high rate of relapse.

25
Q

Mr N, a tall, thin young student, presents to A&E with unilateral left sided chest pain and SOB. He is pale and tachycardic. The upper left lobe is silent on auscultation.

What is the diagnosis?
A. Pneumothorax
B. Panic disorder
C. Tietze's syndrome
D. TIA
E. Oesophageal reflux
F. ACS
G. Coctochondritits
H. Herpes-Zoster
I. Cyclical breast pain
J. Ectopic pregnancy
K. Pulmonary embolism
L. Pleuritis
M. Fibromyalgia
A

A. Pneumothorax

A primary pneumothorax occurs in young people without any known lung conditions. Chest pain, likely to be pleuritic in nature, SOB, pallor, tachycardia and examination findings here are consistent. Having a tall and slender build like this patient is a recognised risk factor. Other risks include smoking, FH, Marfan’s, young age, male and conditions like CF and TB. The main investigation is a CXR and pneumothoraces are classified by the BTS as large (>2cm visible rim between the lung margin and the chest wall) or small (<2cm). If the patient is clinically stable, they can be observed and given oxygen – an invasive approach is not necessary and the oxygen will increase the rate of pneumothorax reabsorption. If large however, percutaneous needle aspiration is required (IV cannula 2nd intercostal space, or 3rd, at the MCL). A CXR should be obtained after this procedure. If this fails, a chest drain should be inserted. If the CXR is normal, then you may start to consider other differentials, and indeed a CXR may even show evidence of PE if this was the case.

26
Q

A 62 year old man presents with fatigue, breathlessness and anorexia. On examination his JVP is noted as being elevated, he has hepatomegaly and swollen ankles and bilateral basal crepitations.

What is the diagnosis?
A. Myocardial infarction
B. Atrial fibrillation
C. Congestive cardiac failure
D. Decubitus angina
E. Right heart failure
F. Left ventricular failure
G. Subacute endocarditis
H. Stable angina
A

C. Congestive cardiac failure

The signs and symptoms this patient has points to CCF (congestive cardiac failure). CCF is a term used for patients who are breathless with oedema (signs of LVF and RVF). Key cardiovascular risk factors this patient may give a history of include hypertension, MI, DM and dyslipiaemia. SOB with possible orthopnoea due to the sudden increase in pre-load, indicates LV failure. The bilateral basal crepitations, heard in late expiration is consistent with pulmonary oedema and is a major Framingham criteria. Neck vein distension is also a major Framingham criteria for diagnosis. Ankle oedema and hepatomegaly is a are minor criteria for diagnosis. Other major criteria for diagnosis include S3 gallop, cardiomegaly and hepatojugular reflux. For all patients, initial investigations should include ECG, CXR, TTE and bloods including BNP levels.

CXR may reveal pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion.

27
Q

A 55 year old man with a history of systemic hypertension presents to A&E with breathlessness on exertion and orthopnoea.

What is the diagnosis?
A. Myocardial infarction
B. Atrial fibrillation
C. Congestive cardiac failure
D. Decubitus angina
E. Right heart failure
F. Left ventricular failure
G. Subacute endocarditis
H. Stable angina
A

F. Left ventricular failure

This patient has presented only with symptoms of left ventricular dysfunction. You should know the distinction between left ventricular failure and right ventricular failure. RVF leads to a backlog of blood and congestion of the systemic capillaries. This causes peripheral oedema and ascites and hepatomegaly may develop. Nocturia may be a symptom as fluid returns from the legs when the patient lies down flat. LVF causes congestion in the pulmonary circulation so the symptoms are respiratory. As seen in this patient, there is SOB on exertion and orthopnoea. This is why you can ask patients in a cardiac history how many pillows they sleep with. PND can also occur as well as ‘cardiac asthma’.

28
Q

A diabetic, 66 year old lady presents to A&E with breathlessness, sweating, nausea and vomiting. She is feeling very distressed. She has no pain. On inspection she appears pale, sweaty and grey.

What is the diagnosis?
A. Myocardial infarction
B. Atrial fibrillation
C. Congestive cardiac failure
D. Decubitus angina
E. Right heart failure
F. Left ventricular failure
G. Subacute endocarditis
H. Stable angina
A

A. Myocardial infarction

This diabetic is having a silent MI without chest pain. Silent MIs are more common in the elderly and those with DM probably due to autonomic neuropathy.

Tachycardia is a common feature of MI especially anterior wall MI. Chest pain of MI is classically severe and heavy in nature, located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are common symptoms. This patient also has pallor which is due to a high sympathetic output. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia. Patients with DM are at increased risk of CAD by a variety of mechanisms which are not fully known.

If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. It is worth noting that RV infarction is present in 40% of inferior infarcts so if ST elevation is seen in II, III and aVF, right sided ECG leads should be obtained. Cardiac biomarkers include CK-MB and troponin.

29
Q

A 49 year old man presents to A&E with a 2 week history of a ‘tight’ central chest pain radiating to the jaw experienced when he is lying down.

What is the diagnosis?
A. Myocardial infarction
B. Atrial fibrillation
C. Congestive cardiac failure
D. Decubitus angina
E. Right heart failure
F. Left ventricular failure
G. Subacute endocarditis
H. Stable angina
A

D. Decubitus angina

Usually as a complication of heart failure. This patient has chest pain which occurs on lying down, which is decubitus angina by definition.

30
Q

A 45 year old man comes to A&E with shortness of breath, giving a history of decreased exercise tolerance. On examination the patient is noted as having an irregular pulse.

What is the diagnosis?
A. Myocardial infarction
B. Atrial fibrillation
C. Congestive cardiac failure
D. Decubitus angina
E. Right heart failure
F. Left ventricular failure
G. Subacute endocarditis
H. Stable angina
A

B. Atrial fibrillation

Irregular HR is the hallmark feature of AF and symptoms here are consistent. Have a think about what the ECG would show.

31
Q

Burning, retrosternal discomfort radiating from epigastrium to jaw & throat. Worse on lying down.

What is the diagnosis?
A. Aortic dissection
B. Angina
C. TB
D. Pneumonia
E. GORD
F. PE
G. Anxiety
H. Oesophageal carcinoma
I. Ruptured AAA
J. Pleural effusion
A

E. GORD

This patient has GORD characterised by heartburn and regurgitation of acid. It is more severe at night when the patient is lying flat and also when the patient is bending over. Risk factors include obesity and hiatus hernia. Diagnosis is generally clinical and can also be achieved by a diagnostic trial of a PPI. Normally an upper GI endoscopy is reserved for complications such as strictures, Barrett’s or cancer, or for atypical features. An OGD may show oesophagitis or Barrett’s (red velvety), however OGD may be normal. Manometry and pH monitoring may also be performed, but in this case, this patient will probably just have a therapeutic and diagnostic trial of a PPI instead of an OGD.

32
Q

Nausea, sweating, central crushing pain, radiating to jaw, lasting a few minutes, which is made worse by exercise.

What is the diagnosis?
A. Aortic dissection
B. Angina
C. TB
D. Pneumonia
E. GORD
F. PE
G. Anxiety
H. Oesophageal carcinoma
I. Ruptured AAA
J. Pleural effusion
A

B. Angina

Whilst this could well sound like an MI, it is not an option on the list. Furthermore, the pain of MI typically lasts for >20 minutes. This patient is suffering from angina. Anti-anginal theray needs to be given, first line being beta-blockade. 2nd line is with a CCB. Long acting nitrates can be used as additional therapy or in patients where beta blockers and CCBs are contraindicated. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.

33
Q

Pain on breathing in & out, dyspnoea, coughing up blood as well, stony dull to percuss.

What is the diagnosis?
A. Aortic dissection
B. Angina
C. TB
D. Pneumonia
E. GORD
F. PE
G. Anxiety
H. Oesophageal carcinoma
I. Ruptured AAA
J. Pleural effusion
A

F. PE

Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. PE can cause atelectasis (deflation of alveoli leading to collapse of a lung, or lobe of a lung) which can result in a dull percussion note and a pleural effusion which is exudative in nature, causing a ‘stony dull’ percussion note. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.

34
Q

Sudden onset chest pain with shortness of breath, coughed blood.

What is the diagnosis?
A. Aortic dissection
B. Angina
C. TB
D. Pneumonia
E. GORD
F. PE
G. Anxiety
H. Oesophageal carcinoma
I. Ruptured AAA
J. Pleural effusion
A

F. PE

Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. PE can cause atelectasis (deflation of alveoli leading to collapse of a lung, or lobe of a lung) which can result in a dull percussion note and a pleural effusion which is exudative in nature, causing a ‘stony dull’ percussion note. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.

35
Q

Collapses with sudden chest pain radiating to back.

What is the diagnosis?
A. Aortic dissection
B. Angina
C. TB
D. Pneumonia
E. GORD
F. PE
G. Anxiety
H. Oesophageal carcinoma
I. Ruptured AAA
J. Pleural effusion
A

A. Aortic dissection

Aortic dissection typically presents with tearing/ripping chest pain and classically radiates through to the back. There may be interscapular pain with dissection of the descending aorta. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. BP differential between the 2 arms is a hallmark feature. Pulse differences may also be present in the lower limbs. There may also be the diastolic murmur of AR in proximal dissections.

36
Q

A 60 year old male smoker complains of severe central chest pain radiating to the left arm. This is post operational following a sigmoidectomy the previous day.

What is the diagnosis?
A. Stable angina
B. Variant angina
C. Pulmonary Embolism
D. Congestive cardiac failure
E. Anxiety
F. Unstable angina
G. Myocardial infarction
H. GORD
A

G. Myocardial infarction

NSTEMI is a common complication of surgical procedures and is often detected as a rise in cardiac markers in the days following surgery. Chest pain of MI is classically severe and heavy in nature, located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are common symptoms. If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia, though there are variations in risk factors attributed to STEMIs and NSTEMIs.

37
Q

A 40 year old obese male presents with a burning chest pain which is worsened by lying down

What is the diagnosis?
A. Stable angina
B. Variant angina
C. Pulmonary Embolism
D. Congestive cardiac failure
E. Anxiety
F. Unstable angina
G. Myocardial infarction
H. GORD
A

H. GORD

This is a common condition and the patient here is complaining of heartburn and acid regurgitation. The diagnosis is easily made clinically as the symptoms the patient describes are worse on lying down or bending over. Typically a patient will describe a burning sensation after meals which is not exertional. Reflux of acid into the mouth can leave a sour taste. Aside from obesity, other strong risk factors include advanced age, family history and hiatus hernia. This patient will need a trial of a PPI which will both be therapeutic and diagnostic. Complications of GORD include stricture formation, Barrett’s and oesophageal carcinoma.

38
Q

A 59 year old female is admitted to A&E with chest pain. The pain is central in origin and came on while she was watching television. The patient has a BMI of 34 and is a known hypertensive. Troponin and CK-MB are not elevated.

What is the diagnosis?
A. Stable angina
B. Variant angina
C. Pulmonary Embolism
D. Congestive cardiac failure
E. Anxiety
F. Unstable angina
G. Myocardial infarction
H. GORD
A

F. Unstable angina

This is UA characterised by chest pain at rest. ECG will typically show ST depression and T wave inversion. Acute management includes antiplatelets and antithrombotics to reduce damage and complications. Long term management aims at reducing risk factors. Key risk factors include obesity, hypertension, smoking, hyperlipidaemia, FH, DM and positive FH. People with diabetes may again present with atypical symptoms. Cardiac biomarkers will not be elevated although in a patient who has had an acute MI days earlier, troponin may remain elevated (remains elevated up to 10-14 days after release). All patients with presumed cardiac chest pain should in the first instance get oxygen, morphine and GTN with antiplatelet therapy in the absence of contraindications.

39
Q

A 62 year old male complains of chest pain at rest. An ECG performed in A&E shows ST elevation. A subsequent angiogram with a provocative agent showed an exaggerated spasm of the coronary arteries.

What is the diagnosis?
A. Stable angina
B. Variant angina
C. Pulmonary Embolism
D. Congestive cardiac failure
E. Anxiety
F. Unstable angina
G. Myocardial infarction
H. GORD
A

B. Variant angina

Variant angina (Prinzmetal) is angina caused by coronary artery vasospasm rather than atherosclerosis. It occurs at rest and in cycles. Many patients will also have some degree of atherosclerosis although not in proportion to the severity of the chest pain experienced. ECG changes are of ST elevation (rather than depression) when the patient is experiencing an attack and a stress ECG will be negative. Patients with Prinzmetal angina are often treated for ACS and indeed, cardiac biomarkers may be raised as vasospasm can cause damage to the myocardium. The gold standard investigation is with coronary angiography and the injection of agents to try to provoke a spasm.

40
Q

A 45 year old merchant banker is referred by her GP to the Rapid Access Chest Pain clinic. She is asked to perform the treadmill test & complains of chest pain 9 minutes into the test.

What is the diagnosis?
A. Stable angina
B. Variant angina
C. Pulmonary Embolism
D. Congestive cardiac failure
E. Anxiety
F. Unstable angina
G. Myocardial infarction
H. GORD
A

A. Stable angina

This patient has presented with stable angina. Resting ECG is often normal and the patient is asymptomatic. However during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia and the patient will complain of chest pain. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.

41
Q

A 49 year old man with recent history of long-haul travel presents with shortness of breath & haemoptysis. He also complains of chest pain & ECG shows sinus tachycardia.

What is the diagnosis?
A. Pericarditis
B. Anxiety
C. Angina
D. Tietze's syndrome
E. Oeshophageal spasm
F. Coronary artery disease
G. Myocardial infarction
H. Hiatus hernia
I. Dissected abdominal aorta
J. Pulmonary embolism
A

J. Pulmonary embolism

Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. This patient has recent air travel, which is actually a weak risk factor but seems to crop up a lot on EMQs. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.

42
Q

A 53 year old lady complains of central “crushing” chest pain, sudden onset & spontaneous remission, with no attributable cause. She has no history of hypertension, current BP is 116/76.

What is the diagnosis?
A. Pericarditis
B. Anxiety
C. Angina
D. Tietze's syndrome
E. Oeshophageal spasm
F. Coronary artery disease
G. Myocardial infarction
H. Hiatus hernia
I. Dissected abdominal aorta
J. Pulmonary embolism
A

B. Anxiety

The presence of anxiety does not exclude a cardiac cause and appropriate investigations are required even if the patient obviously has anxiety.The absence of an attributable cause and the sudden onset and spontaneous remission with no cardiac risk factors make this likely to be due to anxiety.

43
Q

A 73 year old gentleman presents to A&E with sudden “tearing” chest pain, radiating to the back. The house officer on duty notices unequal arm pulses & BP.

What is the diagnosis?
A. Pericarditis
B. Anxiety
C. Angina
D. Tietze's syndrome
E. Oeshophageal spasm
F. Coronary artery disease
G. Myocardial infarction
H. Hiatus hernia
I. Dissected abdominal aorta
J. Pulmonary embolism
A

I. Dissected abdominal aorta

The tearing chest pain suggests aortic dissection. There may also be interscapular pain with dissection of the descending aorta. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. BP differential between the 2 arms is a hallmark feature. Pulse differences may also be present in the lower limbs. There may also be the diastolic murmur of AR in proximal dissections.

44
Q

A 63 year old gentleman develops acute central chest pain, radiating down the left arm. He appears very pale & sweaty, & has a strong family history of ischaemic heart disease.

What is the diagnosis?
A. Pericarditis
B. Anxiety
C. Angina
D. Tietze's syndrome
E. Oeshophageal spasm
F. Coronary artery disease
G. Myocardial infarction
H. Hiatus hernia
I. Dissected abdominal aorta
J. Pulmonary embolism
A

G. Myocardial infarction

Chest pain of MI is classically severe and heavy in nature, located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are common symptoms. This patient also has pallor which is due to a high sympathetic output. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia.

If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. It is worth noting that RV infarction is present in 40% of inferior infarcts so if ST elevation is seen in II, III and aVF, right sided ECG leads should be obtained. Cardiac biomarkers include CK-MB and troponin. Troponins rise 4-6 hrs after onset of infarction and peak at 18-24 hours and may persist for 7-10 days.

45
Q

A 67 year old man recovering from an inferior MI complains of sharp retrosternal chest pain. He comments that leaning forward provides relief of the pain. The attending medical student claims to have heard a “rub” on auscultation.

What is the diagnosis?
A. Pericarditis
B. Anxiety
C. Angina
D. Tietze's syndrome
E. Oeshophageal spasm
F. Coronary artery disease
G. Myocardial infarction
H. Hiatus hernia
I. Dissected abdominal aorta
J. Pulmonary embolism
A

A. Pericarditis

This patient has presented with pericarditis. Symptoms include a sharp and severe chest pain retrosternally which is worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’. There may be diffuse (saddle-shaped) ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. The prior viral infection is a risk factor with the most common pericardial infection being viral. Bacterial purulent pericarditis also occurs. The inflammation is due either to direct viral attack or immune mediated damage. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.

46
Q

A 36 year old man presents with a 2 day history of sharp, central chest pain and mild pyrexia.

What is the diagnosis?
A.	Anxiety
B.	Stable angina
C.	Bornholm disease
D.	Pericarditis
E.	Unstable angina
F.	Deep vein thrombosis
G.	Pulmonary embolism
H.	Dressler's syndrome
I.	MI
A

D. Pericarditis

This patient has presented with pericarditis. Symptoms include a sharp and severe chest pain retrosternally. This is classically worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’. There may be diffuse ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. Thee most common pericardial infection is viral. Bacterial purulent pericarditis also occurs. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.

47
Q

A 48 year old woman, who has been on injections since she was 15 for “sugar”, describes a 2 hour history of nausea, vomiting, sweating and feeling generally unwell.

What is the diagnosis?
A.	Anxiety
B.	Stable angina
C.	Bornholm disease
D.	Pericarditis
E.	Unstable angina
F.	Deep vein thrombosis
G.	Pulmonary embolism
H.	Dressler's syndrome
I.	MI
A

I. MI

This diabetic is having a silent MI without chest pain. Silent MIs are more common in the elderly and those with DM probably due to autonomic neuropathy.

SOB due to pulmonary congestion and sweating due to high sympathetic output are common symptoms. Risk factors for MI incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia. Patients with DM are at increased risk of CAD by a variety of mechanisms which are not fully known. If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. It is worth noting that RV infarction is present in 40% of inferior infarcts so if ST elevation is seen in II, III and aVF, right sided ECG leads should be obtained. Cardiac biomarkers include CK-MB and troponin.

48
Q

A 32 year old woman has a 2 day history of intermittent attacks of a sharp pain over the lower left side of her chest. The pain is exacerbated by movements of the rib cage and the patient tells you it becomes difficult to breathe. She has also felt feverish.

What is the diagnosis?
A.	Anxiety
B.	Stable angina
C.	Bornholm disease
D.	Pericarditis
E.	Unstable angina
F.	Deep vein thrombosis
G.	Pulmonary embolism
H.	Dressler's syndrome
I.	MI
A

C. Bornholm disease

Bornholm disease is caused by Coxsackie B virus and symptoms include the fever seen as well as the characteristic attacks of severe pain in the lower chest, which is exacerbated by small movements of the rib cage, which make it difficult for the patient to breathe.

It is the “intermittent attacks” part of the history that best allows you to distinguish Bornholm disease from pericarditis.

49
Q

A 58 year old man describes feeling very tired with a “dull, pressure” over his chest when climbing up the stairs to his flat.

What is the diagnosis?
A.	Anxiety
B.	Stable angina
C.	Bornholm disease
D.	Pericarditis
E.	Unstable angina
F.	Deep vein thrombosis
G.	Pulmonary embolism
H.	Dressler's syndrome
I.	MI
A

B. Stable angina

This patient has presented with stable angina. Resting ECG is often normal however during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. 2nd line is with a CCB. Long acting nitrates can be used as additional therapy or in patients where beta blockers and CCBs are contraindicated. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.

50
Q

A 19 year old girl describes feeling a sudden onset pain over the right hand side of her chest, that catches her breath. She is not on the contraceptive pill. Urinary b-HCG is positive.

What is the diagnosis?
A.	Anxiety
B.	Stable angina
C.	Bornholm disease
D.	Pericarditis
E.	Unstable angina
F.	Deep vein thrombosis
G.	Pulmonary embolism
H.	Dressler's syndrome
I.	MI
A

G. Pulmonary embolism

Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include the pregnant state of this patient, DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.

51
Q

A 60 year old diabetic man comes to A&E with a 5 hour history of crushing chest pain that was not relieved by his GTN spray

Which is the most appropriate investigation?
A. Reassure and discharge
B. Pulmonary function tests
C. Treadmill exercise ECG
D. Echocardiogram
E. Thyroid function tests
F. D-dimer
G. Chest x-ray
H. U&amp;Es
I. ECG
J. FBC
K. ABG
L. Ultrasound
A

I. ECG

This patient’s crushing chest pain sounds like a myocardial infarction. Chest pain is classically severe and heavy in nature, located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are common symptoms. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia. An ECG is indicated. If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. It is worth noting that RV infarction is present in 40% of inferior infarcts so if ST elevation is seen in II, III and aVF, right sided ECG leads should be obtained.

52
Q

A 60 year old man complains that whenever he walks to the shops, he must stop because of a pain in his chest, that is relieved by a minute of rest.

Which is the most appropriate investigation?
A. Reassure and discharge
B. Pulmonary function tests
C. Treadmill exercise ECG
D. Echocardiogram
E. Thyroid function tests
F. D-dimer
G. Chest x-ray
H. U&amp;Es
I. ECG
J. FBC
K. ABG
L. Ultrasound
A

C. Treadmill exercise ECG

This patient has presented with stable angina. Resting ECG is often normal however during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.

53
Q

A 25 year old basketball player, with very long arms, describes sudden onset chest pain over the left side of his chest. He is very short of breath.

Which is the most appropriate investigation?
A. Reassure and discharge
B. Pulmonary function tests
C. Treadmill exercise ECG
D. Echocardiogram
E. Thyroid function tests
F. D-dimer
G. Chest x-ray
H. U&amp;Es
I. ECG
J. FBC
K. ABG
L. Ultrasound
A

G. Chest x-ray

This patient has developed a primary pneumothorax. Marfan’s syndrome is a risk factor and there are many reports of primary spontaneous pneumothoraces attributed to pulmonary tissue fragility due to defective fibrillin. Primary pneumothoraces occur in young people without known lung conditions. The main investigation is a CXR and pneumothoraces are classified by the BTS as large (>2cm visible rim between the lung margin and the chest wall) or small (<2cm). If the patient is clinically stable, they can be observed and given oxygen – an invasive approach is not necessary and the oxygen will increase the rate of pneumothorax reabsorption. A pneumothorax, if left, is something that resolves by itself over time by reabsorption. Cavemen (and cavewomen) who got pneumothoraces all those years ago didn’t just walk around breathless until they died. If large however, percutaneous needle aspiration is required (IV cannula 2nd intercostal space, or 3rd, at the MCL). A CXR should be obtained after this procedure. If this fails, a chest drain should be inserted.

54
Q

A 28 year old lady is very concerned about having a heart condition as she occasionally feels chest pain. She later admits she is very anxious due to the fact her father recently died from a heart attack.

Which is the most appropriate investigation?
A. Reassure and discharge
B. Pulmonary function tests
C. Treadmill exercise ECG
D. Echocardiogram
E. Thyroid function tests
F. D-dimer
G. Chest x-ray
H. U&amp;Es
I. ECG
J. FBC
K. ABG
L. Ultrasound
A

I. ECG

The presence of anxiety does not exclude cardiac pathology even though anxiety disorder can uncommonly cause chest pain. It is important to do the appropriate investigation workup, particularly as there is a family history of cardiac disease here. There may well be underlying cardiac pathology here which cannot be overlooked.

55
Q

A 22 year old lady, who recently started taking the oral contraceptive pill, suddenly feels chest pain and begins coughing up specs of blood. Modified Wells score shows a low risk of PE.

Which is the most appropriate investigation?
A. Reassure and discharge
B. Pulmonary function tests
C. Treadmill exercise ECG
D. Echocardiogram
E. Thyroid function tests
F. D-dimer
G. Chest x-ray
H. U&amp;Es
I. ECG
J. FBC
K. ABG
L. Ultrasound
A

F. D-dimer

The OCP is a weak risk factor for PE. Clinical probability of PE can be calculated using either the modified Wells score or Geneva scoring system. If the patient is at a low risk of PE then a D-dimer should be measured by ELISA to rule out PE as a diagnosis. If this test is not elevated then PE is effectively ruled out without further testing. If D-dimer is abnormal then a multi-detector CT of the chest is the imaging study of choice with the diagnosis being confirmed by direct visualisation of thrombus in a pulmonary artery (which shows up as a partial or complete intraluminal filling defect). Remember that D-dimer has a high sensitivity for PE but a low specificity. Have a look at the modified Wells criteria to see what the components are. A score of less than or equal to 4 makes a PE unlikely whereas a score greater than 4 makes a PE likely.

56
Q

A 54 year old man develops worsening crushing chest pain (10/10 in intensity) which radiates down his left arm and left side of his neck. He feels light-headed with shortness of breath and is nauseated. He appears sweaty on examination. ECG reveals convex ST elevation in the anterior leads.

Which is the most appropriate first management step?
A. Propranolol
B. Clopidogrel
C. Calcium channel blocker
D. Lovastatin
E. Sublingual GTN
F. Oxygen, Aspirin, Morphine, GTN
G. ACEi
H. Heparin
I. Enoxaparin
J. I.V. magnesium sulphate
K. Synchronised cardioversion
L. Amiodarone
M. Lidocaine
A

F. Oxygen, Aspirin, Morphine, GTN

All patients require oxygen and aspirin should be given on clinical suspicion of ACS and continued indefinitely. Other agents that can be given include beta blockers, GTN, morphine and calcium channel blockers. This combination given from the list is the best first line of management. You would not start beta blockers or consider CCBs before giving the patient these drugs.

57
Q

A 48 year old man complains of chest pain upon walking up his driveway, which is on a hill. The pain disappears if he rests. The doctor prescribes him aspirin and wants to start him on long term anti-anginal therapy.

Which is the most appropriate first management step?
A. Propranolol
B. Clopidogrel
C. Calcium channel blocker
D. Lovastatin
E. Sublingual GTN
F. Oxygen, Aspirin, Morphine, GTN
G. ACEi
H. Heparin
I. Enoxaparin
J. I.V. magnesium sulphate
K. Synchronised cardioversion
L. Amiodarone
M. Lidocaine
A

A. Propranolol

This patient has presented with stable angina. Resting ECG is often normal however during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin (this has been given). Anti-anginal therapy will also be given, first line being beta-blockade which is the correct option here. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary.

58
Q

A 70 year old man with a history of MI suddenly develops palpitations, sweats and dizziness with an overwhelming sense of doom. A minute later he has lost consciousness and collapsed. ECG shows a monomorphic ventricular tachycardia at 150 beats per minute. CPR is initiated to no effect.

Which is the most appropriate first management step?
A. Propranolol
B. Clopidogrel
C. Calcium channel blocker
D. Lovastatin
E. Sublingual GTN
F. Oxygen, Aspirin, Morphine, GTN
G. ACEi
H. Heparin
I. Enoxaparin
J. I.V. magnesium sulphate
K. Synchronised cardioversion
L. Amiodarone
M. Lidocaine
A

K. Synchronised cardioversion

This is haemodynamically unstable VT with a pulse and first line is synchronised cardioversion and treatment of any reversible cause (if present). Do you kow what all the reversible causes of VT are (e.g. ischaemia, MI, toxicity, drug overdose)? Cardioversion may be repeated as needed until rhythm is controlled. Medical treatment can be used as an important adjunct to emergency care with amiodarone and lidocaine being considered here. IV magnesium sulphate is used in torsades de pointes (a special type of VT with a twisting baseline occuring in the setting of long QT) as hypomagnesaemia is frequently associated with the condition.