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Year 3 > Case 1 - Chest Pain > Flashcards

Case 1 - Chest Pain Flashcards

1
Q

What are the 3 characteristics of “typical stable angina”

A

1) Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2) Precipitated by physical exertion
3) Relieved by rest of GTN within about 5 minutes

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2
Q

What is “Atypical angina”

A

Chest discomfort which meets 2/3 of the typical angina characteristics

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3
Q

What is the initial management for typical or atypical angina?

A

FBC test - test for anaemia which can exacerbate angina
Aspirin 75mg OD - unless contraindicated and only in stable angina
ECG - looking for changes associated with coronary artery disease
GTN spray - to relieve symptoms
Drug treatment - beta blocker or calcium channel blocker (only in stable angina)

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4
Q

What are the changes on an ECG which are associated with coronary artery disease?

A

Pathological Q waves
Left bundle branch block
ST segment and T wave abnormalities (flattening or inversion)

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5
Q

What are the ECG characteristics of LBBB?

A

Broad QRS complex
Deep S wave in V1
No Q wave in V5/V6

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6
Q

In which ECG leads are Q waves normally not present?

A

V1-V3

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7
Q

How would you advise someone to use their GTN spray?

A

Use when pain occurs
Stop what you are doing and rest
Use GTN spray as instructed - under tongue
Take 2nd dose in 5 minutes if pain has not eased
Call 999 for an ambulance if pain has not eased after another 5 minutes

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8
Q

What are the types of coronary revascularisation available for patients with ACS?

A

Percutaneous coronary intervention (PCI) - using a balloon or a stent

Fibrolysis

Coronary artery bypass grafting (CABG)

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9
Q

What does an aortic stenosis murmur sound like and where is it best heard?

A

Ejection click murmur between S1 and S2
Heard best at left 2nd intercostal space, left sternal edge
Murmur can radiate to carotid arteries in the neck

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10
Q

What does a mitral Regurgitation murmur sound like and where is it best heard?

A

Pan systolic murmur between S1-S2

Best heard at the apex

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11
Q

What does an aortic regurgitation sound like and where is it best heard?

A

Early diastolic murmur - between S2-S1

Best heard at 4th intercostal space with patient sat forward in expiration

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12
Q

What does a mitral stenosis murmur sound like and where is it best heard?

A

Heard between S2-S1 Opening snap and mid diastolic rumble
Loud S1 sound
Best heard at the apex with patient in left lateral position

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13
Q

What might a 3rd heart sound indicate (S3)?

A

Caused by diastolic filling of the ventricle
Considered a normal varient in patients < 30 years
Heard in left ventricular heart failure - dilated cardiomyopathy, constrictive pericarditis and mitral regurgitation

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14
Q

What is the immediate management for suspected ACS?

A 
Loading dose of Aspirin 300mg
Physical examination 
Bloods - Troponin 
12 lead ECG - if this shows STEMI or new LBBB consider for coronary reperfusion therapy 
Beta blocker IV (unless contraindicated)
Oxygen/Monitor 
Consider clopidogrel in hospital 300mg
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15
Q

What is the triad associated with Cardiac Tamponade?

A

Becks Triad - Low blood pressure (weak pulse), raised JVP, muffled heart sounds

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16
Q

What are the possible complications following an MI?

A 
Cardiac Arrest 
Cardiogenic Shock 
Chronic heart failure 
Tachyarrhythmias 
Bradyarrhythmias - more common after inferior myocardial infarctions 
Pericarditis - common in first 48 hours following 
Left ventricular aneurysm 
Left ventricular free wall rupture 
Ventricular septal defect 
Acute mitral regurgitation
17
Q

What is the difference between pericarditis and Dressler’s syndrome?

A

Pericarditis - occurs 48 hours after MI
Dresser’s syndrome - type of pericarditis that occurs 2-6 weeks following an MI, thought to be due to an autoimmune reaction against protiens as the myocardium recovers

18
Q

What is the management of a STEMI?

A

Aspirin, clopidogrel and unfractionated heparin
Primary percutaneous coronary intervention (PCI)
- thrombolysis should be performed in patients without access to primary PCI
Glycaemic control in patients with diabetes mellitus

19
Q

What are the drugs that patients should be on lifelong following an myocardial infarction?

A

Dual antiplatelet therapy (aspirin + clopidogrel)
ACE inhibitor
Beta Blocker
Statin

20
Q

What are the contraindications to thrombolysis?

A 
Recent haemorrhage, trauma or surgery 
Coagulation and bleeding disorders
Stroke < 3 months 
Intracranial neoplasm 
Aortic dissection 
Pregnancy 
Severe hypertension
21
Q

What ECG changes would you see in 1st degree heart block?

A

Constantly prolonged PR interval

22
Q

What ECG changes would you see in 2nd degree heart block mobitz I?

A

Ever increasing PR interval until QRS complex drops

23
Q

What ECG changes would you see in 2nd degree heart block mobitz II?

A

ORS complexes dropped for no reason

24
Q

What ECG changes would you see in 3rd degree heart block?

A

No relationship between the P waves and the QRS complexes

25
Q

What ECG changes would you see with atrial flutter?

A

Saw tooth P waves

26
Q

How can anaemia cause myocardial ischaemia?

A

Fewer RBCs results in poorer oxygenation

27
Q

What are the non cardiovascular differentials of chest pain?

A 
GORD
Gallstones
Peptic ulcer
Pancreatitis 
PE
Pneumothorax
Pneumonia 
Costochondritis
28
Q

What is the management for NSTEMI/Unstable Angina?

A 
Aspirin 300mg stat 
Clopidogrel for 12 months afterwards 
Fondaparinux if not planning coronary angriography in 24 hours 
Calculate risk of MI using GRACE score 
Secondary prevention discussion
29
Q

What are the different lead orientations on an ECG?

Which arteries supply the areas?

A

I, aVL, V5, V6: lateral (left circumflex)
II, III, avF: inferior (right coronary)
V1, V2: septal (anteroseptal)
V3, V4: anterior (LAD)

30
Q

What arteries would be occluded in an anterior, inferior and lateral MI?

A

Anterior - Left anterior descending
Inferior - right coronary artery
Lateral - circumflex artery

Year 3 (24 decks)

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