cardiac conditions: chest pain Flashcards
What types of cardiac conditions can cause chest pain?
- Ischaemic Heart disease
- Infection- pericarditis/endocarditis
- Arrhythmia
What are associated symptoms that can accompany cardiac chest pain?
- Palpitations
- Syncope
- SOB
SBA 1
76 year old female
Central crushing chest pain- radiates to jaw
ECG= ST elevation in leads II, II, and aVF
SaO2= 89%
Started on drugs before PCI
Which 4 drugs should she be given?
- A) Morphine*
- B) Oxygen*
- C) Aspirin*
- D) Clopidogrel*
- E) Warfarin*
- A) Morphine*
- B) Oxygen*
- C) Aspirin*
- D) Clopidogrel*
SBA 2
54 year old man
Suspected ACS
ECG- ST elevation in aVL, I, V5. V6
What type of MI is this and which coronary artery has been occluded?
Lateral MI
Left circumflex
What are the conditions that make up acute coronary syndrome (ACS)?
- Unstable angina pectoris
- STEMI
- NSTEMI
Stable angina
Definition
Aetiology
Types
Epidemiology
Symptoms + Signs
Investigations
Management
Stable angina
Definition
Aetiology
Epidemiology
Symptoms + Signs
Investigations
Management
Definition
Chest pain caused by triggers such as exertion due to myocardial ischaemia + that is relieved by rest
Aetiology
Blood supply to the heart is less than demand= ischemia
Usually due to atherosclerosis of coronary arteries,
OTHER TYPES
Decubitus angina- triggered by lying down
Coronary syndrome X= Symptoms of angina with no ECG changes
Prinzmetal angina- Coronary vasospasm
Epidemiology
Common
Symptoms + Signs
Central chest pain
Better on resting
Investigations
Gold standard = ECG exercise stress test
FBC
U + E
TFT
Echo?
Management
Conservative: Stop smoking, lose weight/diet, exercise
Medical: Beta blockers/CCBs
GTN spray- when symptoms happen, PRN
+
manage risk factors- aspirin, statins, antihypertensives
Acute coronary syndrome
Definition
Types (and definition of each type)
Aetiology
Symptoms and signs
Epidemiology
Investigations
Management
Complications
Acute coronary syndrome
Definition
Types (and definition of each type)
Aetiology
Epidemiology
Investigations
Management
Complications
Acute coronary syndrome
Definition
Constellation of symptoms- sudden reduced blood flow to myocardium
Types (and definition of each type)
Unstable angina- chest pain at rest due to ischemia, no infarction or cardiac injury
NSTEMI- Non ST elevation myocardial infarction [high troponin]
STEMI- ST elevation myocardial infarction [ST elevation on ECG + high troponin]
Aetiology
Myocardial oxygen demand exceeds supply= ischemia= infarction
Epidemiology
Symptoms and Signs
Acute, sudden onset
Central crushing chest pain
Radiates to arm, neck, jaw
Pallor
Sweating
Dizziness
[Silent/asymptomatic in elderly]
Investigations
1st line: ECG
Troponin (elevated in MI)
Echocardiogram
_____________
ECG findings
Unstable angina/NSTEMI- ST depression, T wave inversion
STEMI= ST elevation, LBBB, hyperacute T waves
Old infarction= pathological/deep Q waves
Management
ACS in general:
Immediate: MONAC
Morphine, Oxygen, Nitrates (short and long acting), Aspirin and Clopidogrel
Long term:
Conservative- diet, exercise, weight
Medical: Beta blockers, + {Risk factors}- hypertensives (ACEi), statins
STEMI
Immediate
- PCI (Percutaneous coronary intervention)
- Fibrinolysis/thrombolysis
If <12 hr from symptom onset:
Can do PCI within 2hr of time that fibrinolysis could be adminstered (within 30 mins of hospital arrival)
If >12 hr:
Do coronary angiogram first to check if can do PCI
NSTEMI/Unstable Angina
MONAC +
- Fondaparinux (factor Xa inhibitor, similar to heparin)- if low bleeding risk or coronary angiography planned in 24hr of admission
- Unfractionated heparin- if coronary angiography planned
Risk factors using GRACE score
If
High risk
GlpIIb/IIIa inhibitor- tirofiban +
Coronary angiography
Low risk
Conservative = control risk factor
Complications
DARTH VADER
Death
Arrhythmia
Rupture of heart muscles
Tamponade
Heart failure
Valve disease
Aneurysm
Dressler’s syndrome
Embolism
Reinfarction
What are antiplatelets used for?
Arterial thrombosis:
MI
Stroke
What are types of disease are anticoagulants used for?
Venous thrombus related disease:
DVT
PE
SBA 3
54 year male
Sharp central chest pain- 24hr
Auscultation- scratching sound- pericardial rub= loudest lower left sternal edge
PMH- STEMI, treated with PCI- 6 weeks ago
A Viral pericarditis
B Constrictive pericarditis
C Cardiac tamponade
D Dressler syndrome
E Tietze syndrome
A Viral pericarditis
B Constrictive pericarditis
C Cardiac tamponade
D Dressler syndrome
E Tietze syndrome
SBA 4
27 year old man
Sharp chest pain
Flu like symptoms
What would you expect to see on his ECG?
A ST elevation in leads II, III and aVF
B Widespread saddle-shaped ST elevation
C ST depression
D Tented T waves
E Absent P waves
Pericarditis
Definition
Aetiology
Risk Factors
Epidemiology
Symptoms
Signs
Investigations + Results
(Management)
Pericarditis
Definition
Inflammation of the pericardium membrane surrounding the heart
Aetiology
Infection- viral -> Coxsackie B, Mumps etc
- Connective tissue disease- sarcoidosis*
- MI (Dressler’s syndrome)*
- Malignancy*
- Idiopathic*
Risk Factors
Recent flu/viral symptoms
Young age???
Post MI- Dressler’s Syndrome
Epidemiology
Young
Male???
Symptoms
Sharp chest pain
Pleuritic pain- worse on inspiration
Alleviated when sittting forward, worse on lying down
Fever/flu-like symptoms (if viral)
Signs
Pericardial rub on auscultation- scratching sound
Tamponade
Investigations + Results
FBC, CRP
ECG- widespread saddle shaped ST elevation (in all leads)
CXR- pericardial effusion may be visible
Management
Broad spectrum antibiotics [if purulent] + NSAIDS
[If viral/idiopathic]- NSAIDS + colchicine [+ anti viral if needed]
SBA 5
46 year old man
Palpitations, since 4hr
ECG shows AF
No PMH of IHD
Refuses DC cardioversion
Next most appropriate step?
A Defibrillation
B Low molecular weight heparin
C Warfarin
D Flecainide
E Digoxin
D Flecainide
SBA 6
27 year old man
Palpitations and lightheadedness
ECG shows SVT
Adenosine given, stops SVT
Repeat ECG shows: Short PR interval + slurred upstroke in QRS complex
Diagnosis?
A Brugada syndrome
B LBBB
C Romano-Ward syndrome
D Wolff-Parkinson-White syndrome
E Complete heart block
D Wolff-Parkinson White syndrome
SBA 7
52 year old man
Palpitations- 45 mins then stopped spontaneously
Several occurences over 2 months
ECG: normal
24 hour tape done: confirms AF
Which scoring system should be used to decide whether long term anti coagulation should be given?
A QRISK2 score
B ABCD2 Score
C GRACE score
D CHA2DS2 -VASc score
E CURB-65 score
D CHA2DS2 -VASc score
Atrial Fibrillation
Definition
Aetiology
Risk factors
Epidemiology
Symptoms
Signs
Investigations + results
Management
Complications (of AF + of AF management)
Prognosis
Atrial Fibrillation
Definition
Irregular, rapid and ineffective atrial contraction- due to uncoordination of electrical impulse conduction in atrial fibres
Aetiology
Many causes
Mitral regurgitation/ stenosis
PIRATES
Pe, pneumonia
Ischemic heart disease
Rheumatic heart disease
Alcohol/ anaemia
Thyrotoxicosis
Electrolyte, endocarditiss
Sepsis, sick sinus syndome
Leukocytosis- ie infection
Risk factors
IHD
Male
Epidemiology
Young
Male
Symptoms
Palpitations
Light headedness??
Syncope
Symptoms of underlying causes of AF
Signs
Irregularly irregular heartbeat
Investigations + results
ECG/24 hour tape= irregularly irregular tachycardia + no p waves (fast AF= tachycardia, slow AF=
Tests for possible underlying causes
Management
- Rhythm control
- Rate control
- Stroke risk management
- Treat underlying cause
Rhythm control
Immediate
If less than 48 hours since AF occured, OR if pt is haemodynamically unstable (SBP<90)
- DC cardioversion
- Chemical cardioversion (flecainide or amiodarone)
If more than 48 hours:
Warfarin/DOAC
+ then DC/chemical cardioversion
Rate controlling medication:
Beta blockers
Verapamil
Digoxin
Long term:
If CHA2DS2 VASC score >2 : Anticoagulate with warfarin/DOAC to decrease stroke risk
Complications (of AF + of AF management)
AF management
Prognosis
When is flecainide contraindicated?
If PMH of ischaemic heart disease
Supraventricular tachycardia
Types
Aetiology/risk factors
Epidemiology
Symptoms
Signs
Investigations + results
Management
Supraventricular tachycardia
Types
AVRT (Atrioventricular reentry tachycardia)- eg. Wolff Parkinson White
AVNRT (Atrioventricular nodal re-entrant tachycardia)
Atrial flutter
Aetiology/risk factors
Infiltrative disease- eg sarcoidosis, amyloidosis- can cause scar tissue in AV node
Epidemiology
Male
Symptoms
Signs
Investigations + results
ECG (+ 24 hour tape)
= regularly irregular, regular tachycardia, no p waves,
Management
1) Haemodynamically stable?
If no = DC cardioversion
If yes=
a) Vagal manoeuvres
b) IV adenosine - 6mg
c) IV adenosine - 12mg
d) IV adenosine- 12mg
d) IV digoxin/beta blockers/amiodarone/DC cardioversion
Verapamil if adenosine contraindicated eg. asthmatics
Wolff Parkinson White
Syncope
Definition
Aetiology/Risk factors
Types/Causes of syncope- Differential diagnosis for presentation
Epidemiology
Symptoms
Signs
Investigations + results
Syncope
Definition
Collapse/transient loss of consciousness due to hypoperfusion of the brain
Aetiology/Risk factors
Vasovagal
= Increased vagal discharge- low HR + CO + BP
Standing for a long time
Fear
Sight of blood
Types/Differential diagnosis for presentation (if cardiac)
VAOP
Vasovagal (nb. only one that is on Sofia)
Arrhythmia
Outflow obstruction- aortic stenosis, HOCM
Postural hypotension (failure to compensate for decrease in blood pressure- due to medications {antihypertensives} + dehydration)
Other rare causes of syncope
Subclavian steal syndrome
Vertebrobasilar insufficiency
Aortic dissection
Non syncopal causes of collapse
Seizures
Head trauma
Metabolic- hypoglycemia, DKA?
Drugs- intoxication
Epidemiology
Young
Symptoms
Before LOC: dizziness, lightheadness, sometimes vision changes- blurring, blackness, sweating
During LOC: Sometimes jerky movements
After LOC: no confusion
Arrhythmia= Palpitations
Signs
Before LOC: going pale
Investigations + results
ECG
Lying- standing blood pressure
Cardio exam- pulse rate and rhythm, + auscultation
Neurological exam
If MI suspected= troponin + cardiac enzymes
(If seizures = creatine kinase also high)
HOCM- Hypertrophic Obstructive Cardiomyopathy
Definition + Aetiology
Risk factors
Symptoms
Signs
Investigations + results
HOCM- Hypertrophic Obstructive Cardiomyopathy
Definition + Aetiology
Hypertrophy of cardiac muscle causes outflow obstruction by blocking the aortic valve
Risk factors
FH of sudden cardiac death aged <65 years old
Symptoms
Palpitations?
Syncope?
Signs
Jerky carotid pulse
Ejection systolic murmur
Double apex beat
Investigations + results
Echo
(Extra card) What is the diagnostic criteria for orthostatic hypertension?
Drop in SBP of 20 mmHg or in DBP of 10 mmHg within 3 minutes of standing
SBA 8
21 year old female
Fainted 4 times in 3 months
Sweating, nauseous and pale before fainting
LOC for few seconds
No loss of control of bladder or tongue biting
After LOC: No confusion, but slight dizziness
What is the most likely cause of her fainting?
A Hypoglycaemia
B Epileptic seizure
C Vasovagal syncope
D Arrhythmia
E Hypertrophic obstructive cardiomyopathy
C Vasovagal syncope
SBA 9
52 year old man
Collapsed 3 times in past couple of months
Father died of cardiac condition at 56 years old
O/E:
Jerky carotid pulse
Crescendo-decrescendo murmur
What is the most likely diagnosis?
A Aortic stenosis
B Hypertrophic obstructive cardiomyopathy
C Left heart failure
D Mitral regurgitation
E Constrictive pericarditis
B Hypertrophic obstructive cardiomyopathy
SBA 10
76 year old man
Collapsed in care home
Suspected hip fracture
LOC on getting up from arm chair
Became consciousness a few seconds later, on floor
Never had a fall
PMH= total knee replacement, heart failure
DH= ramipril, furosemide, bisoprolol
What is the most likely cause of his collapse?
A Vasovagal syncope
B Medication side-effect
C Arrhythmia
D Anaemia
E Dilated cardiomyopathy
B Medication side-effect
SBA 11
A 52-year-old patient is recovering on the cardiology ward after undergoing a valve replacement.
A routine blood test reveals the following results:
Na+ : 135 mmol/L (135 – 145)
K + : 8.7 mmol/L (3.5 – 6.0)
Ca2+ : 0.3 mmol/L (2.2 – 2.6)
An ECG is performed which shows no obvious abnormalities.
Past medical history of hypertension which is treated with ramipril.
Given the above information, what should be the next step in the management of this patient?
A Urgently draw another blood sample
B 10 mL 10% calcium gluconate
C 20 mL 20% calcium gluconate
D 50 mL 50% dextrose + 10 U insulin
E IV salbutamol
A Urgently draw another blood sample
Because
Hyperkalaemia that bad WOULD cause ECG abnormalities
What does this ECG show?
How would you proceed?
Talk it through
tachycardia with regular RR but no p waves with narrow QRS
YOUR differentials:
- Atrial flutter - No flutter visible - so not this one
- Supra ventricular tachycardia - could be
- Sinus tachycardia (maybe P waves hidden) - could be
To distinguish between SVT and ST- do vasovagal manoeuvres and then adenosine- if improves SVT if not ST
What does this ECG show talk through it
Explain the pathology
ECG: normal rate (84 bpm), sinus rhythm, broad QRS, delta wave and short PR interval
(SPECIFIC of Wolf parkinson white syndrome (T wave inversion + ST depression))
Explanation:
- Bundle of KENT conducts impulse down to ventricles - fast tansduction of signal - short PR interval
- Ventricle don’t contract at same time- wide QRS
What drug do you give to Wolff parkinson white patients?
What drug can you not give EVER?
Why not?
What drug do you give to Wolff parkinson white patients? Amiodarone
What drug can you not give EVER?
Adenosine
Beta blocker
- *C**alcium channel blocker
- *D**igoxin
Why not?
lead to VF or VT - because reduce AV node activity - only VT node active and can lead to circuit
What is the pathology in AVRT and AVNRT?
What is the ECG changes that can be seen?
What is their treatment?
AVRT- there is an accessory pathway between the ventricles and the atria
AVNRT- there is circuit within the AV node (most common slow fast)
ECG- tachycardia- p wave can be burried in QRS
AVNRT- try vasovagal moneuvre
BUT otherwhise radiocatheter ablation
- AVRT- destroy accesory pathway
- AVNRT- destroy slow pathway in the AV node
FIll out the table
What is the use of flecainide contraindicated in
Ischaemic heart disease
