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Cardiology > Cardiology- Chest pain > Flashcards

Cardiology- Chest pain Flashcards

1
Q

Cardiac causes of chest pain

A

CAD - ANGINA
Aortic Valve Disease
Pulmonary Hypertension
Mitral Valve Prolapse
Pericarditis
Hypertrophic CMO
Myocarditis

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2
Q

Pulmonary causes of chest pain

A

Pulmonary Embolism
Pneumonia
Pleuritis
Pneumothorax

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3
Q

Vascular causes of chest pain

A

Aortic Dissection
Aortic Aneurysm

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4
Q

Emotional causes of chest pain

A

Anxiety
Depression

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5
Q

Neurological causes of chest pain

A

Cervical Nerve Root
Zoster

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6
Q

Muscular causes of chest pain

A

Costochondritis
Arthritis
Muscular Spasm
Bone Tumour

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7
Q

Gastrointestinal causes of chest pain

A

Peptic Ulcer
GORD
Pancreatitis
Cholecystitis

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8
Q

Major risk factors of chest pain

A

age
gender
family history
high blood cholesterol
high blood pressure
physical inactivity
obesity and overweight
smoking
diabetes
poor diet

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9
Q

Where is angina pain typically located?

A

Angina pain is often felt as retrosternal pain, behind the breastbone.

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10
Q

Where can angina pain radiate?

A

Angina pain commonly radiates down the left arm or into the jaw.

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11
Q

How is angina pain typically described?

A

Angina pain is usually described as crushing or pressing in character.

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12
Q

What physical activities worsen angina pain?

A

Angina pain is worsened by physical activity or emotional stress.

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13
Q

How can angina pain be relieved?

A

Angina pain often improves with nitrates or rest.

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14
Q

What is angina?

A

Angina is chest pain or discomfort caused by reduced blood flow to the heart muscle, often due to coronary artery disease.

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15
Q

What are the main types of angina?

A

The main types are stable angina (predictable and triggered by exertion) and unstable angina (unpredictable, can occur at rest, and may indicate a heart attack).

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16
Q

What are common symptoms of angina?

A

Symptoms include retrosternal chest pain, radiation to the left arm or jaw, shortness of breath, nausea, and sweating.

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17
Q

How long does angina pain typically last?

A

Angina pain usually lasts a few minutes, often subsiding with rest or nitroglycerin.

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18
Q

What factors can trigger angina?

A

Triggers include physical activity, emotional stress, heavy meals, extreme temperatures, and caffeine.

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19
Q

How is angina diagnosed?

A

Diagnosis may involve a medical history, physical examination, ECG, stress tests, and coronary angiography.

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20
Q

What are common treatments for angina?

A

Treatments include lifestyle changes, medications (e.g., nitrates, beta-blockers, ACE inhibitors), and surgical options (e.g., angioplasty, bypass surgery).

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21
Q

Acute chest pain- immediately life threatening conditions

A

Acute Coronary Syndrome
Acute Aortic Dissection
Pulmonary Embolism
Tension Pneumothorax
Pericardial Tamponade
Mediastinitis

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22
Q

Initial evaluation

A

Does this person have an acute coronary syndrome?

Typical angina is easy to recognise but atypical presentations are not uncommon.

Beware in: older patients, women, diabetics, patients with chronic renal failure or dementia!

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23
Q

Helpful clues in patients with atypical presentation

A

Older age
Male sex
Positive family history
Presence of peripheral vascular disease
Presence of risk factors, esp. DM, CRF, previous MI or CABG

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24
Q

What is Acute Coronary Syndrome (ACS)?

A

ACS is a term used to describe a range of conditions associated with decreased blood flow to the heart, including unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI).

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25
Q

What are the main types of Acute Coronary Syndrome?

A

The main types are unstable angina, NSTEMI, and STEMI.

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26
Q

What are the common symptoms of ACS?

A

Symptoms include chest pain or discomfort, shortness of breath, nausea, sweating, and lightheadedness.

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27
Q

What are the risk factors for ACS?

A

Risk factors include smoking, high blood pressure, high cholesterol, diabetes, obesity, sedentary lifestyle, family history of heart disease, and stress.

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28
Q

What diagnostic tests are used for ACS?

A

Diagnostic tests include ECG, blood tests for cardiac biomarkers (like troponin), stress testing, and coronary angiography.

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29
Q

What are common treatment strategies for ACS?

A

Treatment strategies include medications (e.g., aspirin, antiplatelet agents, beta-blockers, ACE inhibitors), revascularization procedures (e.g., angioplasty, stenting), and lifestyle modifications.

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30
Q

What are potential complications of Acute Coronary Syndrome?

A

Complications may include heart failure, arrhythmias, cardiogenic shock, and death.

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31
Q

What is Unstable Angina?

A

Unstable angina is a form of chest pain that occurs unpredictably and can occur at rest or with minimal exertion. It indicates a high risk of myocardial infarction.

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31
Q

What are the common symptoms of Unstable Angina?

A

Symptoms include chest pain or discomfort, shortness of breath, nausea, and sweating. Pain may last longer than typical angina episodes.

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31
Q

What is the immediate management for suspected ACS?

A

Immediate management includes administering aspirin, providing oxygen if needed, and calling for emergency medical help.

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32
Q

How is NSTEMI diagnosed?

A

Diagnosis is based on medical history, ECG, and elevated cardiac biomarkers (like troponin) indicating myocardial injury.

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32
Q

What is NSTEMI

A

Non-ST elevation myocardial infarction (NSTEMI) is a type of heart attack characterized by elevated cardiac biomarkers and ischemic symptoms without ST elevation on the ECG.

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32
Q

How is Unstable Angina diagnosed?

A

Diagnosis typically involves medical history, physical examination, ECG changes, and cardiac biomarkers may be normal or minimally elevated.

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33
Q

What are the symptoms of NSTEMI?

A

Symptoms are similar to unstable angina and include chest pain, radiation to the arm or jaw, shortness of breath, and profuse sweating.

34
Q

What is STEMI?

A

ST elevation myocardial infarction (STEMI) is a severe heart attack characterized by prolonged ischemia, indicated by ST segment elevation on the ECG and significant elevation of cardiac biomarkers.

35
Q

What are the common symptoms of STEMI?

A

Symptoms include severe chest pain (often described as crushing or pressure-like), radiation to the left arm or jaw, shortness of breath, sweating, and nausea.

36
Q

How is STEMI diagnosed?

A

Diagnosis involves ECG showing ST segment elevation, along with elevated cardiac biomarkers indicating myocardial damage.

37
Q

What are common treatment approaches for Unstable Angina, NSTEMI, and STEMI?

A

Treatments may include antiplatelet agents, anticoagulants, beta-blockers, ACE inhibitors, nitrates, and for STEMI, emergency angioplasty or thrombolysis.

38
Q

What are the key ECG findings for STEMI?

A

Key findings include ST segment elevation in two or more contiguous leads, often accompanied by Q waves and T wave inversion later on.

39
Q

What does ACS (no ST elevation) indicate?

A

Acute coronary syndrome without ST elevation (NSTEMI or unstable angina) suggests partial blockage of a coronary artery, leading to myocardial ischemia without complete infarction.

40
Q

What are the ECG findings for ACS (no ST elevation)?

A

Findings include T wave inversion, ST segment depression, and may show normal or slightly elevated cardiac biomarkers for unstable angina. NSTEMI will show elevated cardiac biomarkers.

41
Q

What does “ACS unlikely” mean?

A

“ACS unlikely” indicates that the clinical presentation and ECG findings do not support a diagnosis of acute coronary syndrome

42
Q

What are the ECG findings for ACS unlikely?

A

Findings typically include normal ECG, with no significant ST segment changes or T wave abnormalities, and symptoms not consistent with myocardial ischemia.

43
Q

How can ECG help in categorizing patients?

A

STEMI: ST segment elevation

ACS (No ST elevation): T wave inversion or ST segment depression

ACS Unlikely: Normal ECG

44
Q

Initial therapeutic measures for ACS

A

Oxygen: Insufflation (4-8 L/ min) if oxygen saturation is <90%

Nitrates: Sublingual or intravenous (caution if systolic blood pressure is <90mm Hg)

Morphine: 3-5 mg intravenous or subcutaneously, if severe pain

45
Q

Antithrombotic treatment for ACS

A

Aspirin: Initial dose of 150-300 mg non- enteric formulation followed by 75-100 mg/ day (IV administration is acceptable)

P2Y 12inhibitor: loading dose of ticagrelor or clopidogrel

46
Q

What are cardiac biomarkers?

A

Cardiac biomarkers are substances released into the bloodstream when the heart is damaged or stressed, used to diagnose and assess the severity of cardiac conditions.

47
Q

What are some common cardiac biomarkers?

A

Common cardiac biomarkers include troponin I, troponin T, creatine kinase-MB (CK-MB), myoglobin, and B-type natriuretic peptide (BNP).

48
Q

What is the significance of troponin I and T?

A

Troponin I and T are highly specific to cardiac tissue. Elevated levels indicate myocardial injury and are key in diagnosing myocardial infarction (MI).

49
Q

What does CK-MB indicate?

A

Creatine kinase-MB (CK-MB) is an enzyme found in heart muscle. Elevated levels suggest myocardial injury, but it is less specific than troponin.

50
Q

What is myoglobin, and how is it used?

A

Myoglobin is a protein released when muscle tissue is damaged. It is an early marker for myocardial infarction but is not specific to cardiac tissue.

51
Q

What is BNP and its clinical relevance?

A

BNP is a hormone released in response to heart failure. Elevated levels indicate heart failure severity and help differentiate it from other causes of dyspnea.

52
Q

When do cardiac biomarkers typically rise after myocardial injury?

A

Cardiac biomarkers like troponin usually rise within 3-12 hours after injury, peak at 24-48 hours, and can remain elevated for up to 2 weeks

53
Q

How are cardiac biomarker levels interpreted?

A

Elevated levels indicate myocardial injury, while normal levels can help rule out acute coronary syndrome (ACS). Serial measurements can provide additional information.

54
Q

What are some limitations of cardiac biomarkers?

A

Limitations include false positives due to conditions like renal failure, heart surgery, or muscle injury. Timing of the test and patient characteristics can also affect results.

The negative predictive value of a negative hsTropT on admission is >95%.

Only VERY early presenters will escape detection – a repeat TropT at 3 hrs picks up nearly 100% of patients with MI

55
Q

Patients that need an urgent invasive strategy (i. e. cath lab ASAP)

A

Refractory angina

Recurrent angina associated with high risk ECG (deep ST depression or “arrow-head T waves)

Clinical symptoms of heart failure or shock

Life threatening arrhythmia (VF or VT)

56
Q

Chronic chest pain- physical examination

A
  • Blood pressure (?hypertension)
  • Murmurs
  • Pulses (regular?, present?, bruits? – PVD)
  • Signs of hypercholesterolaemia (tendon xanthomata/xanthelasma)
  • Pallor
57
Q

Chronic chest pain- Investigations

A
  • ECG
  • Effort stress test – diagnostic versus prognostic
  • Full blood count
  • Renal function
  • Fasting blood glucose/HbA1c
  • Fasting lipogram
  • TSH
58
Q

Drugs for chronic chest pain

A

Aspirin
Statin
Beta-blocker/calcium channel antagonist
Sublingual nitrates
Probably ACE-inhibitor

59
Q

What is the role of aspirin in chronic chest pain?

A

Aspirin is an antiplatelet agent that helps prevent blood clots, reducing the risk of myocardial infarction in patients with chronic stable angina.

60
Q

How do statins help in managing chronic chest pain?

A

Statins lower cholesterol levels and stabilize atherosclerotic plaques, reducing cardiovascular risk and improving outcomes for patients with coronary artery disease.

61
Q

What is the mechanism of action of beta-blockers in chronic chest pain?

A

Beta-blockers reduce heart rate and myocardial oxygen demand, improving exercise tolerance and decreasing the frequency of angina attacks.

62
Q

How do calcium channel antagonists contribute to chronic chest pain management?

A

Calcium channel antagonists relax vascular smooth muscle, decreasing myocardial oxygen demand and alleviating angina by improving blood flow to the heart.

63
Q

What is the use of sublingual nitrates in chronic chest pain?

A

Sublingual nitrates provide rapid relief of angina symptoms by dilating coronary arteries and reducing myocardial oxygen demand.

64
Q

What is the potential benefit of ACE inhibitors in chronic chest pain?

A

ACE inhibitors may be beneficial for patients with heart failure or left ventricular dysfunction, as they reduce blood pressure and decrease myocardial workload, but they are not first-line for stable angina.

65
Q

And if the patient still has chest pain

A

Long-acting nitrates

Vasodilatory CCBs such as amlodipine

Ivabradine

66
Q

What is the role of long-acting nitrates in managing chronic chest pain?

A

Long-acting nitrates help to prevent angina attacks by providing sustained vasodilation, reducing myocardial oxygen demand, and improving blood flow to the heart.

67
Q

How do vasodilatory CCBs like amlodipine help with chronic chest pain?

A

Amlodipine and other vasodilatory CCBs relax vascular smooth muscle, decreasing vascular resistance and myocardial oxygen demand, which helps relieve angina symptoms.

68
Q

What is the mechanism of action of ivabradine in treating chronic chest pain?

A

Ivabradine specifically inhibits the “funny” current (I_f) in the sinoatrial node, reducing heart rate without affecting contractility, which decreases myocardial oxygen demand and alleviates angina.

69
Q

What are common side effects of long-acting nitrates?

A

Common side effects include headache, dizziness, hypotension, and tolerance with long-term use.

70
Q

What are potential side effects of amlodipine?

A

Side effects may include peripheral edema, headache, flushing, and palpitations.

71
Q

What considerations should be made when prescribing ivabradine?

A

Ivabradine is particularly beneficial for patients with stable angina and a resting heart rate of 70 bpm or higher who are not suitable for beta-blockers.

72
Q

Management of stable coronary disease

A

A. ASPIRIN, ANTI-ANGINALS, ACE-INHIBITORS
B. BETA-BLOCKERS AND BLOOD PRESSURE
CHOLESTEROL, CIGARETTES AND CALCIUM
ANTAGONISTS
D. DIET AND DIABETES
E. EDUCATION AND EXERCISE
F. FAMILY, FRIENDS, FINANCIAL SUPPORT

73
Q

And if the patient still has angina

A

Revascularisation – surgical or percutaneous

74
Q

What is the main action of Streptokinase?

A. dissolves clot by its enzymatic breakdown of fibrin
B. anticoagulates by inhibiting formation of thrombin
C. it inhibits platelets
D. enhances the activity of antithrombin and thereby prevents clot formation

A

A. dissolves clot by its enzymatic breakdown of fibrin

75
Q

Which lifestyle modification is important for patients who have had an Acute Coronary Syndrome?

A. smoking cessation
B. weight loss
C. regular exercise
D. all of the above

A

D. all of the above

76
Q

If measured from onset of angina, when does reperfusion benefit have the highest mortality benefit in a patient presenting with an acute STEMI?

A. in the first hour
B. 1 – 3 hours
C. 3 – 6 hours
D. > 6 hours

A

A. in the first hour

77
Q

Where does chest pain caused by myocardial ischaemia typically radiate?

A. left arm
B. interscapular
C. epigastrium
D. retro-orbital

A

A. left arm

77
Q

What is the MOST COMMON mechanism that results on ST elevation myocardial infarction?

A. vessel occlusion by growing atherosclerotic plaque rupture
B. vessel occlusion by thrombus formation due to atherosclerotic plaque rupture
C. vasospasm
D. vessel occlusion by coronary thromboembolism

A

B. vessel occlusion by thrombus formation due to atherosclerotic plaque rupture

78
Q

Which patients with suspected myocardial infarction are likely to benefit from early reperfusion therapy with a thrombolytic agent?

A. patients with ST segment depression on ECG
B. patients with ventricular fibrillation
C. patients with ST elevation
D. patients with normal ECGs

A

C. patients with ST elevation

79
Q

What is the 6-month mortality rate of patients presenting with an Acute Coronary Syndrome?

A. 5%
B. 13%
C. 22%
D. 37%

A

B. 13%

80
Q

Which platelet receptor does Clopidogrel inhibit?
A. P2Y12
B. TXA2
C. ADP
D. GP2b/3a

A

A. P2Y12

81
Q

What should happen to patients who present with a STEMI and fail to reperfuse with timely administration of a thrombolytic agent?

A. discharge on aspirin
B. referral for emergency percutaneous coronary intervention (PCI)
C. admission on heparin
D. repeated dose of thrombolytic drug

A

B. referral for emergency percutaneous coronary intervention (PCI)

82
Q

Which ONE of the following conditions can cause angina?

A. hypertension
B. coronary artery disease
C. aortic stenosis
D. all of the above

A

D. all of the above

83
Q

Measured from onset of angina, in patients who have a myocardial infarction when is Troponin usually detected in peripheral blood by high sensitivity assays?

A. after 4 hours
B. after 8 hours
C. after 12 hours
D. after 24 hours

A

A. after 4 hours

84
Q

Which territory of the heart is affected if a patient has ST elevation in the chest leads V1 – V6?

A. right ventricle
B. inferior left ventricular wall
C. anterior/septal left ventricular wall
D. posterior left ventricular wall

A

C. anterior/septal left ventricular wall

85
Q

Patients with non-ST elevation ACS should be anticoagulated with which agent?

A. statin (HMG-CoA Reductase Inhibitor)
B. low molecular weight heparin (Clexane)
C. warfarin (Vitamin K antagonist)
D. aspirin (platelet inhibitor)

A

B. low molecular weight heparin (Clexane)

86
Q

Which lipid particle is involved in the pathogenesis of atherosclerosis?

A. HDL
B. Chylomicrons
C. VLDL
D. LDL

A

D. LDL

87
Q

Which ONE of the following drugs / drug classes improves the survival of patients with stable coronary artery disease?

A. calcium channel blockers
B. short acting nitrates
C. beta-blockers
D. statins (HMG-CoA Reductase Inhibitors)

A

D. statins (HMG-CoA Reductase Inhibitors)

Cardiology (4 decks)

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