Cardiology Chest Pain Flashcards
A 76-year-old woman is brought into A&E with central crushing chest pain that radiates to her jaw and left arm. An ECG is performed, which shows ST elevation in leads ll, lll and aVF. Her SaO2 is 89%. Before she is sent to the cathlab for percutaneous coronary intervention, she is started on a combination of drugs. Which of the following should not be given? A Morphine B Oxygen C Aspirin D Clopidogrel E Warfarin
E Warfarin
IMPORTANT: warfarin causes an initial pro-thrombotic phase because it blocks protein C and protein S. Therefore, heparin must be co-administered with warfarin to begin with, until the INR stabilises (between 2-3).
A 54-year-old man has been brought into A&E with a suspected acute coronary syndrome. An ECG is performed, which reveals ST elevation in leads I, aVL, V5 and V6. Which coronary artery has been occluded?
A Left main stem
B Left anterior descending coronary artery
C Left circumflex coronary artery
D Right coronary artery
E Posterior descending artery
C Left circumflex coronary artery
What is decubitus angina
When symptoms occur when lying down
What is prinzmetal angina
When symptoms are cause by coronary vasospasm
What is coronary syndrome X
When patients have symptoms of angina but with normal exercise tolerance and normal coronary angiograms
What is the conservative management of stable angina
stop smoking
lose weight
exercise
Alongside conservative management for stable angina what else should you give
Anti-platelet therapy:
aspirin 75-150mg orally once daily
or/and
clopidogrel 75mg orally once a day
Alongside conservative management for stable angina what else should you give
Anti-platelet therapy:
aspirin 75-150mg orally once daily
and/or
clopidogrel 75mg orally once a day
What is the medical management for stable angina
anti-anginal therapy
BB (metoprolol 50-200mg orally twice daily, propranolol 20-60mg orally twice daily)
and/or
CCB (nifedipine 30-90mg orally once daily, amlodipine 5-10mg orally once daily)
and/or
GTN for symptomatic control
What are the three main features of angina
- constricting discomfort in the chest or neck, shoulders, jaw and arms
- precipitated by exercise
- relieved by rest or GTN within 5 minutes
If a patient have all 3 features of angina, this is known as …
typical angina
If a patient has 2/3 features of angina, this is known as …
atypical angina
If a patients has 1/3 features of angina, this is known is …
likely to be non-anginal pain
Stable angina is a clinical diagnosis but what other investigation can be used to diagnose angina
Exercise ECG
Looking for ST-segment depression to identify ischaemia
In stable angina, what can be done if medical treatment in ineffective
PCI (percutaneous coronary intervention) such as a stent
CABG
Define acute coronary Syndrome
A constellation of symptoms caused by sudden reduced blood flow to the heart muscle
What are the 3 conditions that encompass acute coronary syndrome
- Unstable angina pectoris - chest pain at rest due to ischaemia without cardiac injury
- Non-ST elevation MI
- ST-elevation MI
How do you distinguish between ACS:
unstable angina
NSTEMI
STEMI
- Clinical history
- ECG changes
YES: STEMI
NO: elevated troponin
YES: NSTEMI
NO: unstable angina
What are the signs and symptoms of acute coronary syndrome
acute-onset central, crushing chest pain
radiates to arms/neck/jaw
pallor
sweating
Note: silent infarts in elderly and diabetics
What are the ECG changes in a STEMI
hyperacute T waves, ST elevation, new onset LBBB
What are the ECG changes in an unstable angina/NSTEMI
ST depression, T wave inversion
What features on an ECG suggests an old infarct
pathological Q waves
Troponins are elevated in
both STEMI and NSTEMI suggesting myocardial injury
ST depression/elevation in leads II, III and aVF suggest an infarct where
inferior (right coronary artery)
An inferior infarction has ST elevation in which leads
Leads II, III, aVF
ST depression/elevation in leads V1-5 suggest an infarct where
Anterior (left anterior descending)
ST depression/elevation in leads I, avL, V5-6 suggest an infarct where
lateral (left circumflex)
Tall R waves and ST depression in V1-3 suggests an infarct in which part of the heart
posterior (posterior descending)
What coronary arteries supply the: inferior: anterior: lateral: posterior: portion of the heart
Inferior: RCA (right coronary artery)
Anterior: LAD (left anterior descending)
lateral: left circumflex
posterior: posterior descending
The posterior descending coronary artery is a branch of what coronary artery
RCA (right coronary artery)
in 70% of cases
What is the general ACS management
MONA BASH Morphine Oxygen Nitrates Antiplatelets (aspirin + clopidogrel)
Beta-blockers
Ace-inhibitors
Statins
Heparin
What is the aim of STEMI treatment
Coronary reperfusion either by PCI or fibrinolysis
ACS: if a patient presents < 12 hours from the onset of symptoms
Send to cathlab for PCI, if pt presents within 120 mins fibrinolysis can be administered
ACS: if a patient presents > 12 hours from the onset of symptoms
coronary angiography followed by PCI if indicated
What is the immediate management of NSTEMI/UAP
- Aspirin + other antiplatelet (e.g. clopidogrel, ticagrelor)
- Fondaparinux (factor Xa inhibitor): if low bleeding risk unless coronary angiography is planned 24 hrs of admission
- LMWH: if coronary angiography is planned
What scoring system do you use to stratify patients with ACS
GRACE score
If a patients presents as high risk on the GRACE scoring system, what is their management plan
- GlpIIb/IIIa inhibitor (e.g. tirofiban)
2. coronary angiography within 72 hours
If a patients presents as low risk on the GRACE scoring system, what is their management plan
conservative management (control risk factors)
Complications od ACS
DARTH VADER Death Arrhythmia Rupture Tamponade Heart failure
Valve disease Aneurysm Dressler's syndrome Embolism Reinfarction
A 54-year-old man is complaining of sharp, central chest pain that has arisen over the last 24 hours. On inspection, the patient is sitting forward on the examination couch. On auscultation, a scratching sound is heard – loudest over the lower left sternal edge, when the patient is leaning forward. He has a past medical history of a ST-elevation MI which was diagnosed, and treated with PCI, 6 weeks ago. What is the most likely diagnosis? A Viral pericarditis B Constrictive pericarditis C Cardiac tamponade D Dressler syndrome E Tietze syndrome
D Dressler syndrome
A 27-year-old man presents complaining of sharp chest pain. He mentions that he has taken a few days off work recently because of the flu. 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
B Widespread saddle-shaped ST elevation
What are the signs and symptoms of pericarditis
- Sharp, central chest pain
- pleuritic (pain during inspiration)
- relived by sitting forward
- fever/flu-like symptoms (if viral)
- pericardial friction rub
- tamponade (if pericardial effusion)
What is the treatment of pericardial effusion
pericardiocentesis
if pericardial effusion is causing tamponade
What are the features of tamponade
Beck’s Triad:
Muffled heart sounds
Raise JVP
low blood pressure
What are the ECG features of pericarditis
Widespread saddle-shapped ST elevation
What investigation would you do if you suspect pericarditis
- ECG (widespread saddle shaped ST elevation)
- Bloods: FBC, CRP (raised, also increase in WBC count)
- Serum troponin (mildly raised)
- CXR (pericardial effusion)
What is Tietze syndrome
a rare inflammatory disorder characterised by chest pain and swelling og the cartilage of one or more of the upper ribs (costochondral junction), specifically where the ribs attach to the sternum
Define atrial fibrillation
Characterised by rapid, chaotic and ineffective atrial electrical conduction
What are examples of the causes of AF
- Pneumonia
- PE
- hyperthyroidism
- Ischaemic heart disease
- alcohol
- pericarditis
A 46-year-old man has been admitted to A&E after experiencing palpitations, which began about 4 hours ago. An ECG is performed, which reveals atrial fibrillation. He has no previous history of ischaemic heart disease. He refuses DC cardioversion. What is the next most appropriate treatment option? A Defibrillation B Low molecular weight heparin C Warfarin D Flecainide E Digoxin
D Flecainide
A 27-year-old man presents with palpitations and light-headedness. An ECG shows features consistent with a supraventricular tachycardia. Adenosine is administered and the SVT is terminated. A repeat ECG shows a short PR interval and a QRS complex with a slurred upstroke. What is the diagnosis? A Brugada syndrome B LBBB C Romano-Ward syndrome D Wolff-Parkinson-White syndrome E Complete heart block
D Wolff-Parkinson-White syndrome
A 52-year-old man was watching TV yesterday when he suddenly become very aware of his heart beating rapidly. This lasted for around 45 mins and then subsided spontaneously. It has happened several times over the past 2 months. An ECG reveals no abnormalities. However, due to the strong suspicion of atrial fibrillation, the patient is placed on a 24-hr tape, which confirms the diagnosis. Which scoring system should be used to determine the benefit of long-term anticoagulation in this patient? A QRISK2 score B ABCD2 Score C GRACE score D CHA2DS2-VASc score E CURB-65 score
D CHA2DS2-VASc score
AF management: rhythm control
<48hrs since onset of AF
1. DC cardioversion
or chemical cardioversion (flecainide or amiodarone)
Note: flecainide is contradicted if there is a history of IHD
> 48hrs since onset of AF
1. anticoagulate for 3-4 weeks before attempting cardioversion
AF management: rate control
- verapamil
- beta-blockers
- Digoxin
Once a patient is diagnosed with AF, what scoring system stratifies stroke risk
CHADS-Vasc score
>1 suggests anticoagulation should be considered
CHADS-Vasc score: If a patient is low risk, what should be administered
aspirin or none
CHADS-Vasc score: If a patient is high risk, what should be administered
warfarin
Define supraventricular tachycardia
a regular, narrow-complex tachycardia with no p waves and a supraventricular origin
What are the symptoms on supraventricular tachycardia
- palpitations
- syncope
- dyspnoea
- chest discomfort
What are the 2 types of supraventricular tachycardia
- Atrioventricular Nodal Re-entry tachycardia (AVNRT)
- A local circuit formes arounds the AV node - Atrioventricular Re-entry tachycardia
- A re-entry circuit forms between the atria and ventricles due to the presence of an accessory pathway
(Bundle of Kent)
What are the investigation and findings for supreventricular tachycardia
- ECG
regular
narrow complex tachycardia
absent p waves
Supraventricular tachycardia: how do you distinguish between AVNRT and AVRT
ECG after termination of SVT
AVNRT: normal
AVRT: ‘delta wave’ (slurred upstroke on QRS complex)
A presence of an accessory pathway resulting in a delta wave on ECG (AVNT) is known as
Wolff-Parkinson-White Syndrome
Supraventricular tachycardia: Management
STEP 1: is the patient haemodynamically stable?
NO: Synchronised DC cardioversion
YES: STEP 2
STEP 2: Vagal Manoeuvres – did it work?
YES: Good Job
NO: STEP 3
STEP 3a: IV Adenosine 6 mg – did it work?
YES: Good Job
NO: Step 3b, if that fails, Step 3c, then, Step 4
STEP 3b: IV Adenosine 12 mg
STEP 3c: IV Adenosine 12 mg (again
STEP 4: Choose from: IV b-blocker (e.g. metoprolol) IV amiodarone IV digoxin Synchronised DC cardioversion
Supraventricular tachycardia: Management
STEP 1: is the patient haemodynamically stable?
NO: Synchronised DC cardioversion
YES: STEP 2
STEP 2: Vagal Manoeuvres – did it work?
YES: Good Job
NO: STEP 3
STEP 3a: IV Adenosine 6 mg – did it work?
YES: Good Job
NO: Step 3b, if that fails, Step 3c, then, Step 4
STEP 3b: IV Adenosine 12 mg
STEP 3c: IV Adenosine 12 mg (again)
STEP 4: Choose from: IV b-blocker (e.g. metoprolol) IV amiodarone IV digoxin Synchronised DC cardioversion
What is the vagal manoeuvre
carotid body message, blowing against a syringe
Supraventricular tachycardia: normally administer adenosine, what do you administer instead for an asthmatic
verapamil
Define syncope
a form of loss of consciousness in which hypo-perfusion to the brain is the cause
A 21-year-old woman has fainted 4 times in the past 3 months. She becomes sweaty and nauseous before she faints and is usually unconscious for a few seconds. Her friends have told her that she looks abnormally pale before she collapses. She doesn’t know if she jerks whilst unconscious, but has not lost control of her bladder or bitten her tongue. When she regains consciousness, she feels slightly dizzy but does not feel confused. 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
A 52-year-old man has collapsed 3 times in the past couple of months. His father died of a heart condition when he was 56 years old, although he cannot recall the details of the condition. On examination, a jerky carotid pulse is palpated and a crescendo-decrescendo murmur is heard over the carotid artery. 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
A 76-year-old man is found collapsed in the care home
and has a suspected hip fracture. He says that he
temporarily lost consciousness as he got up from his arm
chair and came about, a matter of seconds later, on the
floor. He has never experienced a fall before. He has a
past medical history of a total knee replacement and
heart failure which is treated with ramipril, furosemide and
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
What are the differential diagnosis for syncope
VAOP 1. Vasovagal may feel sweaty and pale before collapse 2. Arrhythmia (can lead to low-output state, may have palpitations before collapse) 3. Outflow obstruction (e.g. aortic stenosis, HOCM) 4. Postural hypotension
What are the clinical features of Hypertrophic Obstructive Cardiomyopathy (HOCM)
Clinical Features: jerky carotid pulse double apex beat ejection systolic murmur family history of sudden death at a relatively young age (<65 years)
What other pathologies are syncopal causes
- Vertebreobasillar insufficiency
- subclavian steal syndrome
- Aortic dissection
What are non-syncopal causes of collapse
- Intoxication
- Head trauma
- Metabolic (e.g. hypoglycaemia)
- Epileptic seizure
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. He has a 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
