Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Semester 1 ( 3rd Year) > Case 5: Central Chest Pain > Flashcards

Case 5: Central Chest Pain Flashcards

1
Q

How can coronary artery occlusion lead to heart failure?

A
  1. blockage of coronary artery
  2. ischaemia and MI
  3. necrosis
  4. inflammatory response to remove dead cells
  5. infarct healing and scar formation
  6. hypertrophy, dilation and reduced function
  7. heart failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

describe the chest pain in a pneumothorax

A

sudden onset pleuritic chest pain either left sided or right sided with associated dyspnoea and syncope

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

describe the chest pain in MSK

A

pain is normally persistent and is worsened with passive and active motion and sometimes chest tenderness on palpation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

describe the chest pain in stable angina

A

exertional pain or discomfort in the centre of left side of chest, throat, neck or jaw - it is relieved by rest or GTN within a few minutes. it may radiate to the neck/jaw/left arm. there also may be breathlessness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

describe the chest pain in pericarditis

A

constant or intermittent central pleuritic harp pain which is often aggravated by position (worse on lying down and relieved by sitting or leaning forward)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

describe the chest pain in peptic ulcer disease

A

recurrent and vague epigastric discomfort which is relieved by food or antiacids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

describe the chest pain in PE

A

sudden onset pleuritic chest pain with associated dyspnoea and tachycardia. sometimes mild fever, haemoptysis and syncope

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what are the cardiac causes of central chest pain?

A

acute coronary syndrome
stable angina
thoracic aorta dissection
myocarditis
pericarditis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

describe the chest pain in thoracic aorta dissection

A

Sudden, tearing pain radiating to the back

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

what are the respiratory causes of chest pain?

A

pulmonary embolism
tenion pneumothorax
pneumonia
pleurisy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what are the GI causes of chest pain?

A

oesophageal rupture
peptic ulcer disease
pancreatitis
gallstones
hepatitis
GERD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

what is the pathophysiology of stable angina?

A

atherosclerosis and atheroma formation results in progressive narrowing of the lumen in a coronary artery

at rest there is no chest pain but during exertion the myocardial demand rises and the supply cannot meet the myocardial demand resulting in an exertional chest pain that is relieved by rest or GTN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what is the pathophysiology of ACS?

A

an unstable plaque can rupture resulting in platelet aggregation and thrombus formation which can cause sudden occlusion of the coronary artery. this results in acute chest pain called ACS

the degree and duration of the occlusion will dictate the subtype of ACS

  1. total and persistent occlusion = STEMI
  2. partial or temporary occluion = NSTEMI or unstable angina
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what is the pathway for a patient coming to hospital with chest pain?

A

all patient with acute chest pain (lasting more than 15 minutes) will need an immediate 12 lead ECG to exclude ST elevation. if there is no ST elevation then the patient will need to undergo 6 hour troponin testing
if troponin is elevated = NSTEMI
and if not = unstable angina

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what are the 3 main diagnostic features of angina?

A
  1. constricting discomfort in the front of chest, neck, shoulders and arms
  2. precipitated by physical exertion
  3. relieved by GTN or rest in about 5 minutes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what are the sub types of angina?

A

they depend on how many of the typical diagnostic features are present:
3 - typical angina
2 - atypical angina
1/0 - non angina

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

what are the main risk factors for angina?

A

smoking
hypertension
hyperlipidaemia
low LDL
diabetes
male
obesity
family history
ilicit drug use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what investigations do you carry out for someone with suspected angina?

A
  • detailed chest pain history (SOCRATES)
  • cardiovascular examination
  • BP/BMI
  • 12 lead ECG
  • routine bloods: FBC, renal function, glucose, troponins (to rule out ACS)

diagnostic tests:
1. CT coronary angiogram (gold standard)
2. stress ECHO, MRI regional wall, SPECT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

what ECG changes can be seen in stable angina?

A

pathological Q waves
LBBB
ST segment changes
T wave changes

all indicative of CAD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what is the RAMP management of stable angina?

A

R - refer to cardiology
A - advise of diagnosis and self management
M - medication treatment
P - procedural/surgical intervention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

what is the medical management of stable angina? contradindications?

A

FOR IMMEDIATE SYMPTOMATIC RELIEF:
- GTN spray is used as required in acute attacks. take and repeat after 5 minutes is required

FOR LONG TERM SYMPTOMATIC RELIEF:
- beta blocker (bisoprolol)
- calcium channel blocker (amlodipine)

CONTRAINDICATIONS:
As monotherapy, a rate-limiting calcium channel blocker should be used such as verapamil
When in combination with a beta blocker, a long acting calcium channel blocker should be used, e.g. modified release nifedipine
Verapamil should not be used with a beta blocker if there is a risk of complete heart block.

22
Q

what medications do we give for secondary prevention of stable angina?

A

4 A’S:
Aspirin
Atorvostatin
ACE inhibitor
Already on beta blocker for symptomatic relief

23
Q

what is the general lifestyle advice given to someone with stable angina?

A

smoking cessation
glycaemic control
hypertension control
hyperlipidaemia control
weight loss
reduce alcohol intake

24
Q

what are the surgical interventions for stable angina?

A

PCI:
percutaneous coronary intervention
this involves putting a catheter into the patient’s brachial or femoral artery and feeding it up into the coronary artery and injecting a contrast so that any areas of stenosis are highlighted on xray and then this can be treated with balloon dilatation and insertion of a stent

CABG:
opening the chest along the sternum and taking a graft vein from the patients leg and sewing it onto the affected coronary artery to bypass the stenosis.

25
Q

what are the three types of acute coronary syndrome?

A

unstable angina - this is angina that occurs at rest for extended periods of time or a new onset severely increased form of stable angina. no sign of myocardial ischaemia

NSTEMI - caused bys evre/incomplete stenosis of a coronary artery. MI presenting complaints with evidence of biochemical myocardial ischaemia and some ECG changes

STEMI - complete compromise to coronary perfusion presenting as an MI with definitive ECG changes and evidence of biochemical MI

26
Q

what is the typical pain of ACS?

A

S - central/left sided pain
O - sudden onset
C - crushing (weight on chest)
R - left arm, neck and jaw
A - nausea, vomiting, sweating, SOB, syncope
T - constant
E - stress and exertion worse, GTN may help
S - often unbearably extreme

27
Q

what is the typical presentation of someone with ACS?

A

central and constricting chest pain associated with:
nausea
vomiting
sweating
SOB
palpitations
pain radiating to the arm/jaw

28
Q

what are the risk factors for ACS?smoking

A

hypertension
lDL
obesity
diabetes
stress
diet
physical inactivity
age
male
family history
BAME

29
Q

what investigations do you carry out for someone with suspected ACS?

A

physical examination
bloods
ECG (most important)
CXR
CT angiogram
echocardiogram

30
Q

how do you diagnose unstable angina?

A

cardiac chest pain + abnormal/normal ECG + normal troponin (after serial repeats)

31
Q

how do you diagnose NSTEMI?

A

cardiac chest pain + abnormal/normal ECG (no ST elevation) + raised troponin

32
Q

how do you diagnose STEMI?

A

cardiac chest pain + persistent ST elevation/new LBBB

33
Q

how do you differentiate between a NSTEMI and stable angina?

A

We differentiate between a NSTEMI and unstable angina by performing a blood test. Raised troponin and/or other ECG changes (ST depression/T wave inversion/pathological Q waves) then diagnosis is NSTEMI. Normal troponin and ECG with no pathological changes = unstable angina, or another cause e.g. MSK chest pain

34
Q

what ECG changes can be seen in a STEMI/NSTEMI?

A

NSTEMI
-ST segment depression in a region
- Deep T wave inversion/flattening
- Pathological Q waves

STEMI
- ST segment elevation >1mm in adjacent limb leads (I, II, III, aVF, aVL)
à ST segment elevation >2mm in adjacent chest leads (V1-V6)
à New left bundle branch block with chest pain or suspicion of MI

35
Q

is tropnonin a good investigation?

A

it is a cardiac regulatory protein that controls the interaction between myosin and calcium and is released in cardiac damage

it is not specific as it is also raised by:
- pericarditis
- myocarditis
- arrhythmias
- defibrilation
- acute heart failure
- PE
- type A aortic dissection
- prolonged exercise

36
Q

what is the acute treatment of ACS?

A

MONA
M - Morphine
O - oxygen if saturation is less than 94%
N - nitrates
A - aspirin
C - clopidogrel or ticagrelor

37
Q

what is the acute treatment of a STEMI?

A

if someone presents with a STEMI, within 12 hours of onset of symptoms:
1. primary PCI (if available within 2 hours of presentation)
2. thrombolysis (if PCI is not available within 2 hours)

PCI discussed earlier
thrombolysis involves inhecting a fibrinolytic medication to rapidly dissolve clots but does pose a risk of bleeding

38
Q

what fibrinolytics are used in thrombolysis?

A

streptokinase
alteplase
tenectoplase

39
Q

what is the acute treatment of a NSTEMI?

A

BATMAN
B - beta blockers
A - aspirin
T - ticagrelor or clopidogrel
M - morphine
A - anticoagulant (LMWH) N - nitrates

40
Q

what is a GRACE score?

A

this is the scoring system used to assess the need for PCI in a STEMI. it gives a 6 month risk of death or repeat MI after having a NSTEMI
<5% low risk
5-10% medium risk
>10% high risk

41
Q

what is the secondary prevention of ACS?

A

6 A’s
A - aspirin
A - antiplatelet (ticagrelor or clopidogrel)
A - atorvostatin
A - ace inhibitor (ramipril)
A - atenolol (beta blocker)
A - aldosterone antagonist (eplerenone)

42
Q

what are the types of MI?

A

type 1 = traditional MI due to acute coronary event

Type 2 = ischaemia secondary to increased oxygen demand or reduced supply of oxygen (e.g. severe anaemia, tachycardia or hypotension)

type 3 = sudden cardiac death or cardiac arrest suggestive of an ischaemic event

type 4 = MI associated with procedures such as PCI or coronary stenting

43
Q

what is dressler’s syndrome?

A

Post MI (2-3 weeks) localised immune response - delayed pericarditis
Presents with pleuritic chest pain, low grade fever, pericardial rub on auscultation

Diagnosis:
- ECG global ST elevation and T wave inversion
- Echo - pericardial effusion
- Raised inflammatory markers - CRP and ESR

Management is with NSAIDS (aspirin/ibuprofen) and in more severe cases with steroids such as prednisolone. May need pericardiocentesis to remove the fluid from around the heart.

44
Q

what is the pathophysiology of aortic dissection?

A

it is a rare but serious cause of chest pain. it occurs when there is a tear in the intima of the wall of the aorta. high pressure blood in the aorta then begins to tunnel between the intima and media which separetes the 2 layers. as more of the tunica intima is shed from the tunica media blood starts to pool between the 2 layers and becomes a bulge

45
Q

what are the risk factors for aortic dissection?

A

chronic hypertension
trauma
bicuspid aortic valve
marfans syndrome
turners and noonan’s syndrome
pregnancy
syphillys

46
Q

what are the symptoms of an aortic dissection?

A

chest pain radiating to the back. typically a severe and harp pain tearing in nature which is maximal at onset

pulse deficit - weak or absent pulse OR variation (>20mmHg) in systolic BP between the arms

pulsus paradoxus

muffled heart sounds

distended neck veins

aortic regurgittaion

hypertension

47
Q

what is pulsus paradoxus?

A

moderate to severe cardiac tamponade, and occasionally constrictive pericarditis, induce haemodynamic changes that enhance the inspiratory fall in systolic BP (>10mmHg). this exaggerated drop in systemic BP during inspiration is termed pulsus paradoxus.

48
Q

what are the two classifications of aortic dissection?

A

type A - ascending aorta. 2/3 of cases, more typically chest pain

type B - descending aorta distal to left subclavian. 1/3 of cases, more typically back pain

49
Q

what are the complications of aortic dissection?

A
  1. Blood can flow back up the aorta to the heart and fill the pericardial space leading to cardiac tamponade.
  2. Blood flowing through the false lumen can also puncture a hole through the tunica media and externa. Blood can then flow into the mediastinum.
  3. Blood could continue to flow between the 2 layers until it reaches another artery that branches off the aorta e.g. renal/subclavian. Blood in the false lumen can put pressure on these branches arteries, decreasing blood flow to the area respectively
50
Q

what investigations are carried out for aortic dissection?

A

CT angiography of the chest abdomen and pelvis is the investigation of choice. It is suitable for stable patients and for planning surgery. The main diagnostic finding is a false lumen.
For more unstable patients a transoesophageal echocardiography is more suitable.

51
Q

what is the treatment of an aortic dissection?

A

Aortic dissection needs to be treated immediately

Type A
Treated surgically. Dissected aorta is removed. This blocks the entry of blood into the wall of the aorta. Wall is then reconstructed with synthetic graft

Type B
Conservative management. Treated with beta blocker and nitroprusside and bed rest.

Semester 1 ( 3rd Year) (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions