Case 1 - Chest Pain Flashcards
What are the 3 characteristics of “typical stable angina”
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
What is “Atypical angina”
Chest discomfort which meets 2/3 of the typical angina characteristics
What is the initial management for typical or atypical angina?
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)
What are the changes on an ECG which are associated with coronary artery disease?
Pathological Q waves
Left bundle branch block
ST segment and T wave abnormalities (flattening or inversion)
What are the ECG characteristics of LBBB?
Broad QRS complex
Deep S wave in V1
No Q wave in V5/V6
In which ECG leads are Q waves normally not present?
V1-V3
How would you advise someone to use their GTN spray?
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
What are the types of coronary revascularisation available for patients with ACS?
Percutaneous coronary intervention (PCI) - using a balloon or a stent
Fibrolysis
Coronary artery bypass grafting (CABG)
What does an aortic stenosis murmur sound like and where is it best heard?
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
What does a mitral Regurgitation murmur sound like and where is it best heard?
Pan systolic murmur between S1-S2
Best heard at the apex
What does an aortic regurgitation sound like and where is it best heard?
Early diastolic murmur - between S2-S1
Best heard at 4th intercostal space with patient sat forward in expiration
What does a mitral stenosis murmur sound like and where is it best heard?
Heard between S2-S1 Opening snap and mid diastolic rumble
Loud S1 sound
Best heard at the apex with patient in left lateral position
What might a 3rd heart sound indicate (S3)?
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
What is the immediate management for suspected ACS?
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
What is the triad associated with Cardiac Tamponade?
Becks Triad - Low blood pressure (weak pulse), raised JVP, muffled heart sounds
What are the possible complications following an MI?
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
What is the difference between pericarditis and Dressler’s syndrome?
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
What is the management of a STEMI?
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
What are the drugs that patients should be on lifelong following an myocardial infarction?
Dual antiplatelet therapy (aspirin + clopidogrel)
ACE inhibitor
Beta Blocker
Statin
What are the contraindications to thrombolysis?
Recent haemorrhage, trauma or surgery Coagulation and bleeding disorders Stroke < 3 months Intracranial neoplasm Aortic dissection Pregnancy Severe hypertension
What ECG changes would you see in 1st degree heart block?
Constantly prolonged PR interval
What ECG changes would you see in 2nd degree heart block mobitz I?
Ever increasing PR interval until QRS complex drops
What ECG changes would you see in 2nd degree heart block mobitz II?
ORS complexes dropped for no reason
What ECG changes would you see in 3rd degree heart block?
No relationship between the P waves and the QRS complexes
