Case 1 - Chest Pain

Question 1

Differentials for chest pain

Describe their symptoms

Answer 1

ACS - tight, crushing chest pain, radiates to shoulder, neck, arms, jaw, sweaty and clammy. Lasts minutes to hours

Angina - as for ACS, but worsened on exertion, and relieved by rest/GTN

Aortic dissection - shearing, ripping pain, radiating to the back. Lasts minutes/seconds

GORD - indigestion, epigastric pain, associated with eating

PE - pleuritic chest pain and SOB

MSK/costochondritis - worse on touching, lasts hours to days. Achey pain

Pericarditis - central chest pain, relieved by sitting up

Question 2

What is ACS?

Answer 2

Spectrum of disease from unstable angina > NSTEMI > STEMI

Question 3

What is the definition of unstable/stable angina?

Answer 3

Stable angina meets all of:

• constricting chest/neck/jaw pain
• Worsened or precipitated by exertion
• Relived by rest/GTN within 5 minutes

Unstable angina only meets 2 of above

Question 4

Pathophysiology of ACS

Answer 4

Atherosclerotic plaque
Plaque ruptures
Narrowed lumen in vasoconstriction
Decreased blood flow through coronarys 
Ischaemia of tissues

Question 5

Image of heart arteries

Answer 5

LAD
R marginal
L circumflex
Posterior descending
L marginal

https://www.bing.com/images/search?view=detailV2&ccid=d9E0vd75&id=4CCBE3469C99E47480355DD4F8F7A664061E84B2&thid=OIP.d9E0vd75wmoHWEnv13dBEwHaFr&mediaurl=https%3a%2f%2fclassconnection.s3.amazonaws.com%2f158%2fflashcards%2f4596158%2fpng%2fcoronaryarteries-1455F7D19E7727884A9.png&exph=1082&expw=1409&q=heart+arteries&simid=607994368161156592&ck=8D7AA4F330573661A6EC65A22A339DCE&selectedIndex=0&FORM=IRPRST&ajaxhist=0

Question 6

Image of heart veins

Answer 6

Coronary sinus
Great cardiac vein
Middle cardiac vein
Small cardiac vein

https://www.bing.com/images/search?view=detailV2&ccid=MX05Xwvd&id=67256057A02DF94CC9AF4977DC06DBE0816BFBC3&thid=OIP.MX05Xwvdj1_pBbpMeRMIugHaFS&mediaurl=http%3a%2f%2fwww.wikidoc.org%2fimages%2fc%2fc4%2fFigure_04.GIF&exph=1500&expw=2100&q=heart+veins&simid=608052685160646114&ck=2ACB0399CD8CDA8D00FC2079E419D6E6&selectedIndex=11&qpvt=heart+veins&FORM=IRPRST&ajaxhist=0

Question 7

Risk factors for ACS

Answer 7

Increasing age
HTN
Hyperlipidaemia
Smoker
Alcohol excess
Poor diet
Lack of exercise
Psychosocial stress

Question 8

Investigations for ACS

Answer 8

1) ECG
2) Troponins and other bloods
3) CT angiography
4) Non-invasive testing if CT angiogram is inconclusive e.g. echo

Question 9

Potential ECG changes in ACS

Answer 9

A normal ECG does not rule out ACS

V1 and V2=Septal
V3 and V4=Anterior
V5 and V6 and leads I, aVL=lateral
Leads II, III and avF=inferior

May see STEMI and reciprocal depression - elevation=infarction, depression=ischaemia
Pathological (broad) Q waves may indicate previous MI

Question 10

At what intervals should you perform an ECG?

Answer 10

At 0, 3, 6, 24 hours

Question 12

What might troponins show in MI?

Answer 12

Troponins should be performed at baseline
Greater than 50% rise in 6 hours is diagnostic of MI
Start to rise at 2-4 hours post-MI, peak at 24-48 hours

Troponins I and T are cardio-specific, but rise could be due to a number of cardiac pathologies and therefore are not specific for MI
Unstable angina will not have a rise in troponin as there is no necrosis

Question 13

What might CT angiography show?

When is it indicated?

Answer 13

Inject dye, and then can visualise the blood supply to the heart
Can see areas of narrowing
Indicated in:
-angina
-ST changes

Question 14

What is the initial treatment for a STEMI?

Answer 14

Morphine for analgesia
Oxygen if sats<96% ORA
Nitrates ie. GTN
Aspirin - 300mg loading dose
Clopidogrel

Question 15

What is the treatment for stable angina?

Answer 15

Stop exertion and rest
Take GTN spray
Wait 5 mins
If symptoms not relieved, take a 2nd spray
Wait 5 mins
If symptoms not relives, call 999

Question 16

What is the treatment for unstable angina and NSTEMI?

Answer 16

Loading dose of 300mg aspirin
Give fondaparinux unless CT angio planned within 24hours (clopidogrel instead)
Perform CT angiography in any patient above low risk
Consider stents, CABG, PCI etc.
Aspirin and ticagrelor for 12 months
Clopidogrel add on for higher risk
Glycoprotein inhibtiors add on for higher risk

Question 17

What is the treatment for a STEMI?

Answer 17

Assess eligibility for coronary reperfusion
Give coronary angiography with PCI if:
-present within 12 hours of onset of symptoms
-PCI can be given within 2 hours of when fibrinolysis can be given
PCI could insert stents, aspirate thrombus etc.
Otherwise give alteplase, and coadminister anti-thrombin and reassess for PCI
Perform ECG at 60-90mins, if still in STEMI, perform coronary angio and PCI

Question 18

Long-term drugs that might be given following ACS?

Answer 18

Beta blockers
Statins
ACE-i/ARB
Antiplatelets/anticoagulants

Question 19

Complications of an MI

Answer 19

Death
Arrythmia - particular if infarct in RA
Rupture - if of ventricular wall could > tamponade
-if of papillary muscle > valvular inversion > regurgitation
-if of ventricular wall > mixing of blood > hypoxaemia > further damage
Tamponade
Heart Failure

Valvular disease
Aneurysm
Dresslers - a secondary pericarditis following autoimmune response
Embolism
Regurgitation

Question 20

Describe the normal heart sounds and the anatomy they correspond to

Answer 20

Normal heart sounds are S1 and S2
S1 is start of systole
S2 is start of diastole
S1 is the closure of the mitral and tricuspid valves
S2 is the closure of aortic and pulmonary valves

Question 21

Describe the features of aortic stenosis

Answer 21

An ejection click systolic murmur, as the blood initially flows very quickly through the valve and then decreases speed very quickly
Radiates to the carotids
2nd RICS

Question 22

Describe the features of mitral regurgitation

Answer 22

5th LICS MCL
Pan-systolic murmur
Radiates to the axilla
Causes:
-rheumatic heart disease
 -IHD
-Valvular vegetations
-Physiological - due to dilated LA

Question 23

Describe the features of tricuspid regurgitation

Answer 23

4th LICS
Pan systolic murmur
No radiation

Question 24

Describe the features of pulmonary stenosis

Answer 24

Ejection click systolic murmur
2nd LICS
No radiation

Question 25

How do you classify the intensity of a murmur?

Answer 25

Grade 1 - murmur only heard after a long period of auscultation
Grade 2 - faint murmur heard on auscultation immediately
Grade 3 - loud murmur heard immediately on auscultation but no thrill
Grade 4 - palpable thrill and loud murmur

Question 26

How can you describe a murmur?

Answer 26

Intensity - as before
Location where it is heard the loudest
Any radiation
Timing
Shape - crescendo-decresndo etc.
Response to manoeuvres
Pitch
Quality

Question 27

What could be the reasons for murmurs?

Answer 27

Decreased blood viscosity e.g anaemia
Decreased diameter of vessel/valve/orifice
Increased viscosity through normal structures e.g. hyperthyroidism, sepsis
Regurgitation across incompetent valve

Question 28

What manoeuvres could you perform to accentuate a murmur?

Answer 28

Leaning forwards accentuates aortic murmurs
Auscultation the carotids with breath held accentuates aortic stenosis
Leaning left accentuates mitral and tricuspid murmurs

Question 29

What is the normal function of Troponins?

Answer 29

Prevent the cross- binding of myosin and therefore inhibit the contraction of muscle
As calcium concentration increases, the troponin is inhibited, so cross-binding can occur and the muscle can contract