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Year 3 OSCE > Case 1- Chest Pain > Flashcards

Case 1- Chest Pain Flashcards

1
Q

What is the TIMI score used for?

A

Calculates risk of further cardiac event in UA/ NSTEMI patients
Score above 3- coronary angiography recommended

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2
Q

Investigations required in suspected ACS

A

Physical examination
ECG- can be normal
Bloods- troponin I+T, FBC (anaemia), UE (ACE-I), glucose and HbA1C, LFT (statin), lipid profile, TF
CXR- exclude other causes/ pulmonary oedema
Echocardiogram- used after event to assess functional damage
CT Coronary angiography- gold standard

NB- GP wouldn’t do troponin. This could also be investigation ladder for stable angina

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3
Q

Investigations required for stable angina

A

ECG- stress ECG to look for ischaemia
FBC- Hb (anaemia)
Fasting lipid profile- metabolic syndrome
Fasting blood glucose/ HbA1c- metabolic syndrome
TFT’s- hyperthyroidism
CT angiography- gold standard for measuring CAD

NB- anaemia and hyperthyroid are causes of angina chest pain

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4
Q

Ivabradine

A

Patient must be in sinus rhythm

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5
Q

Ranolazine

A

Caution in heart failure, elderly, decreased BMI, prolonged QT

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6
Q

Nicorandil

A

Contraindicated in pulmonary oedema, hypotension, hypovolaemia, LVF, diverticulitis (see below);

NB- can ulcers that can occur anywhere along the gastrointestinal tract. They are refractory to treatment and most only respond to withdrawal of treatment.

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7
Q

Post-PCI procedure

A

Requires dual anti platelet therapy for 12 months

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8
Q

ECG changes and stable angina

A

May show ST segment changes when symptomatic or during a stress ECG

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9
Q

Differences between myocarditis and pericarditis

A

P- pleuritic pain, improves on leaning forward, pericardial rub

M- flu-like prodrome, signs of heart failure eg. bibasal crackles, ST changes in specific terrorties (akin to ACS), not widespread like pericarditis

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10
Q

ECG changes with myocarditis

A

Non specific ST segment and T wave abnormalities but ST segment elevation and depression can occur

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11
Q

Risk factors for aortic dissection

A

HTN
Marfan’s
Elders-Danlos
Smoking
Bicuspid aortic valve
Coarctation of the aorta
FHx aortic dissection

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12
Q

Management of an aortic dissection

A

Beta blocker, if rupture- vasodilator (after BB)
Stanford A- surgery (aortic root replacement if originating at valve)
Stanford B- conservative management

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13
Q

ACS differentials

A

Aortic dissection, pericarditis, stable angina pectoris, PE, pneumothorax, pleurisy, oesophageal spasm, costochondritis, rib fracture

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14
Q

ECG changes pericarditis

A

Inwards concave ST segment elevation globally with PR depressions

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15
Q

Investigations for suspected pericarditis

A

ECG- ST segment elevation globally with PR depressions
Bloods- FBC, UE, troponin (I&T- can be raised), CRP and ESR (raised)
CXR- normal (unless pericardial effusion)
TTE (all patients should have one)

NB- can arise secondary to malignancy (ie. may have lung cancer with a pleural effusion and pericarditis)

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16
Q

Investigations for suspected myocarditis

A

ECG- non specific T wave and ST segment abnormalities
Bloods- FBC UE troponin (I&T- raised) ERS CRP
CXR

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17
Q

LV aneurysm

A

Persistent ST elevation 4 weeks after sustaining an MI
Bibasal crackles
3 and 4 heart sounds

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18
Q

ACS Poor prognostic factors

A

Age
Heart failure
PVD
Reduced systolic BP
Killip class
Initial serum creatinine concentration
Elevated initial cardiac markers
Cardiac arrest on admission
ST segment deviation

KILLIP

1- no signs of heart failure
2- lung crackles, S3
3- frank pulmonary oedema
4- cardiogenic shock

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19
Q

GTN side effects

A

Hypotension
Tachycardia
Headache

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20
Q

Where to avoid statins

A

Pregnancy

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21
Q

Initial ACS management

A

MONA

Morphine (if required)
Oxygen (if sats below 94%)
Nitrates (careful in hypotension)
Aspirin (300mg)

22
Q

Additional STEMI management if patient is undergoing PCI

A

Give praugrel if not on an anticoagulant (clopidogrel if they are)
Give heparin + glycoprotein IIb/IIIa inhibitors (abciximab)

23
Q

Additional STEMI management if someone is receiving fibrinolysis/thrombolysis

A

Give an antithrombin (heparin)
Give ticagrelor
If ongoing, repeat ECG at 60-90 minutes and consider PCI

24
Q

STEMI Criteria

A

Wait for lecture

25
NSTEMI/UA management
Aspirin 300mg Heparin (fondaparinux) if no immediate PCI GRACE <3%: + ticagrelor GRACE >3%: PCI (+ticagrelor/heparin)
26
Conservative management of NSTEMI/UA
GRACE score less than 3% Aspirin + Ticagrelor (not at a high bleeding risk) or clopidogrel (if at high bleeding risk)
27
Coronary angiography for NSTEMI/UA
Within 72 hours if GRACE score more than 3%, or immediately if clinically unstable (with PCI) Give prasugrel/ ticagrelor if not taking an anticoagulant, clopidogrel if they are Give heparin
28
Miscellaneous angina management
1) GTN spray, lifestyle modification, aspirin, statin 2) BB, CCB NB- calcium channel blocker as monotherapy-verapamil or diltiazem, if used in combination with a beta-blocker, use nifedipine or amlodipine (never give BB and verapamil) 3) If a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine NB- If the patient’s symptoms continue after the use of drug management then the patient can then be referred for PCI or bypass graft assessment.
29
Isosorbide mononitrate
Asymmetric dosing regimes should be used for standard-release ISMN to prevent nitrate tolerance (ie. in morning and afternoon)
30
DVLA requirements following PCI
For a private vehicle (group 1), patients do not need to notify the DVLA following PCI and may resume driving after 1 weeks providing they don't have any other disqualifying condition. For a Group 2 vehicle (bus or lorry), patients must notify the DVLA, and may not drive for at least 6 weeks. After 6 weeks the DVLA will assess to determine if the requirements for exercise or other functional tests are met and to ensure there is no disqualifying condition
31
Investigation of choice for suspected aortic dissection
CT angiography- stable TOE- unstable
32
What is pyrexia defined as
Temperature above 38 degrees C
33
Causes of pericarditis
viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism malignancy
34
Management of pericarditis
all patients with suspected acute pericarditis should have transthoracic echocardiography
35
Most common cause of death post-MI
V fib
36
What MI can pre-dispose to a bradyarrhythmia (AV block)
Inferior MI
37
Dressler's syndrome
Fever and pleuritic chest pain 4 weeks post-MI Raised ESR Give NSAIDs
38
Ventricular aneurysm
Persistent ST elevation (may get thrombus in the aneurysm- anticoagulate)
39
Left ventricular free wall rupture
Acute heart failure secondary to cardiac tamponade- raised JVP, pulsus parodoxus, diminished heart sounds
40
Ventricular septal defect post-MI
Acute heart failure and pan-systolic murmur
41
Acute mitral regurgitation post-MI
Typically due to inferior/posterior MI's causing papillary muscle rupture Acute hypotension, pulmonary oedema, systolic murmur
42
Re-infarction blood test
Creatine kinase (CK-MB) remains elevated for 3 to 4 days following infarction. Troponin remains elevated for 10 days. This makes CK-MB useful for detecting re-infarction in the window of 4 to 10 days after the initial insult
43
Statin's and liver function
Treatment with statins should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.
44
Primary prevention CVD
When QRISK3 is greater than 10% atorvastatin 20mg OD
45
Secondary prevention CVD
After someone has angina/MI 4A's; A – Aspirin (plus a second antiplatelet such as clopidogrel for 12 months) A – Atorvastatin 80mg A – Atenolol (or other beta-blocker – commonly bisoprolol) titrated to maximum tolerated dose A – ACE inhibitor (commonly ramipril) titrated to maximum tolerated dose
46
Additional ACS management if due to cocaine
Patients with MI secondary to cocaine use should be given IV benzodiazepines as part of acute (ACS) treatment
47
Basic ACS management
MONA 2nd AP and AC eg. fondaparinux (NSTEMI)/heparin (STEMI) Reperfusion therapy (STEMI- if within 12 hours onset and can be delivered in 120 mins, NSTEMI- depends on GRACE score- if more than 3% PCI within 72 hours, if unstable, immediately) Long-term management (4A's) NB- fibrinolysis if PCI not administered for STEMI (failure to stop infarction- PCI)
48
2nd AP choice
if the patient is not taking an oral anticoagulant: prasugrel if taking an oral anticoagulant: clopidogrel
49
Wellen's syndrome
Resolved chest pain in a patient with deeply inverted T waves in V2-3 → ?Wellen's pattern, suggestive of critical stenosis of the left anterior descending artery (LAD)
50
Synchronised vs unsynchronised DC cardioversion
Synchronised- when patient still has a pulse ie. tachycardia with signs of shock/myocardial ischaemia Unsynchronised- pVT/VF (shockable rhythms)
51
Diabetes control after MI whilst in CCU
type 2 diabetics are converted to intravenous insulin in the immediate period following a myocardial infarction.
52
Classification of ACS
If there is ST elevation or new left bundle branch block the diagnosis is STEMI. If there is no ST elevation then perform troponin blood tests: If there are raised troponin levels and other ECG changes (ST depression or T wave inversion or pathological Q waves) the diagnosis is NSTEMI If troponin levels are normal and the ECG does not show pathological changes the diagnosis is either unstable angina or another cause such as musculoskeletal chest pain

Year 3 OSCE (61 decks)

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