Central Chest Pain

Question 1

What is atherosclerosis?

Answer 1

A chronic inflammatory process triggered by the accumulation of cholesterol-containing low-density lipoprotein (LDL) particles in the arterial wall.

Question 2

When does coronary blood flow predominantly occur?

Answer 2

During diastole – when the myocardium is relaxed and the smaller coronary vessels penetrating through the muscle layers to take blood to the deeper layers of the myocardium are not squeezed by the contracting myocardium.

Question 3

Name the key branches of the right and left main coronary vessels. (5)

Answer 3

Right - right marginal and posterior descending
Left - left anterior descending, left marginal and left circumflex

Question 4

What is the coronary sinus?

Answer 4

A collection of veins joined together on the posterior side of the heart to form a large vessel that collects deoxygenated blood from the myocardium of the heart and delivers it to the right atrium.

Question 5

What are the main symptoms and signs of thoracic aortic dissection? (4)

Answer 5

Sudden, tearing pain radiating to back.
Syncope
Stroke
Leg ischaemia

Question 6

What are the main signs indicative of thoracic aortic dissection? (2)

Answer 6

Pulsus paradoxus
Difference in BP in both arms.

Question 7

What is pulsus paradoxus?

Answer 7

An exaggerated fall in the patient’s blood pressure greater than 10mmHg during inspiration.

Question 8

What type of pain is typically experienced in pericarditis?

Answer 8

Constant or intermittent sharp pain, often aggravated by breathing or position (classically worse on lying down and relieved by sitting or leaning forward).

Question 9

What signs are indicative of acute coronary syndrome (ACT)? (4)

Answer 9

Sinus tachycardia
Xanthelasma
Tar staining on fingers
A new pansystolic murmur (mitral regurgitation)

Question 10

What three types of coronary disease does acute coronary syndrome (ACS) refer to?

Answer 10

Unstable angina
Non-ST-elevation MI
ST-elevation MI

Question 11

What are the main symptoms of myocarditis? (5)

Answer 11

Fever
Dyspnoea
Fatigue
Chest pain (if myopericarditis) which may be pleuritic
Recent viral or other infection

Question 12

What type of pain is indicative of oesophageal rupture?

Answer 12

Sudden, severe pain following vomiting or instrumentation.

Question 13

What group of symptoms are indicative of pancreatitis, gallstones/cholecystitis or hepatitis? (3)

Answer 13

Pain in epigastrium or lower chest, often worse when lying flat and relieved by leaning forward
Vomiting
Upper abdominal tenderness

Question 14

What are the three main symptoms of shingles?

Answer 14

Sharp, band-like pain in the thorax unilaterally
Classic linear, vesicular rash
Pain may precede rash by several days

Question 15

In which ECG leads is it acceptable to have T wave inversion?

Answer 15

aVR, V1 and lead III

Question 16

What changes on an ECG should be considered suspicious for coronary artery disease? (4)

Answer 16

-ST segment elevation/depression
-T wave abnormalities (hyperacute T-waves or T-wave inversion)
-Pathological Q waves (abnormal width or depth, or seen in leads V1-3)
-Left bundle branch block (LBBB –> broad QRS, deep S wave in V1 and no Q wave in V5/6)

Question 17

What three clear diagnostic features do the NICE guidelines provide for typical angina chest pain?

Answer 17

Constricting discomfort in front of chest, neck, shoulders and arms.
Pain precipitated by physical exertion
Pain relieved by GTN or rest in about 5 minutes.

Question 18

What is the pathophysiology of stable angina?

Answer 18

Narrowing of the coronary artery lumen means that at rest there is no chest pain, but during exertion myocardial demand rises, and supply cannot meet this demand, resulting in exertional chest pain relieved by rest or GTN.

Question 19

What is coronary artery disease (CAD)?

Answer 19

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

Question 20

Briefly describe the pathophysiology of acute coronary syndrome (ACS).

Answer 20

An unstable plaque can rupture, resulting in platelet aggregation and thrombus formation which can cause sudden occlusion of the coronary artery, resulting in acute chest pain.

Question 21

What are the subtypes of acute coronary syndrome (ACS) dictated by?

Answer 21

The degree and duration of occlusion of the coronary artery:
-STEMI = total and persistent occlusion.
-NSTEMI/unstable angina = partial or temporary occlusion.

Question 22

What should be the next investigation for somebody who has had acute chest pain lasting more than 15 minutes, and does not have ST elevation on ECG?

Answer 22

6 hour troponin test - normal levels 6 hours after pain onset excludes MI, whilst elevated levels indicate NSTEMI.

Question 23

What is the name of the tool used in General Practice to determine somebody’s cardiovascular risk?

Answer 23

QRISK3 score - score which establishes patient’s 10 year risk of cardiovascular events.

Question 24

What advice should you give a patient with coronary artery disease (CAD) for when they have an episode of chest pain? (4)

Answer 24

Stop what they are doing and rest
Use GTN spray as instructed (single puff once seated)
Take a second dose of GTN after five minutes if pain persists
Call 999 if pain persists for 15 minutes despite use of sublingual GTN, or earlier if pain is intensifying or you feel unwell.

Question 25

How can coronary artery disease (CAD) present? (5)

Answer 25

Silent ischaemia (where no chest pain is experienced)
Stable/unstable angina
STEMI/NSTEMI
Heart failure
Sudden death

Question 26

What is the gold standard biomarker for acute coronary syndrome (ACS)?

Answer 26

Troponin

Question 27

What drugs does NICE recommend should be given in dual antiplatelet therapy for patients with an acute ST elevation myocardial infarction?

Answer 27

Aspirin alongside prasugrel (if they are not already taking an oral anticoagulant) OR clopidogrel (if they are already taking an oral anticoagulant).

Question 28

What drugs should be offered for secondary prevention in those who have had a myocardial infarction (MI)? (4)

Answer 28

-ACE inhibitor
-Dual antiplatelet therapy (aspirin plus second antiplatelet) unless they have a separate indication for anticoagulation
-Beta-blocker
-Statin

Question 29

What symptoms are classically indicative of aortic dissection?

Answer 29

Sudden, tearing pain radiating to the back; sometimes accompanied by syncope, stroke or leg ischaemia.

Question 30

What signs are classically indicative of aortic dissection? (4)

Answer 30

Pulsus paradoxus
Difference in BP across both arms of 20mmHg or more.
Tachycardia
Diastolic murmur

Question 31

What are the two Stanford classifications of aortic dissection?

Answer 31

Type A - dissection involving the ascending aorta.
Type B - dissection not involving the ascending aorta.

Question 32

What is aortic dissection?

Answer 32

An intimal tear in the lining of the aorta, leading to subsequent movement of blood through the tear between the intima and medial layers of the aorta, giving rise to a true and false lumen.

Question 33

What is the GRACE risk score?

Answer 33

A tool that provides risk stratification of mortality from myocardial infarction in 6 months - 3 years time in patients with acute coronary syndrome both STEMI and non-STEMI. Can be calculated both at hospital admission and at discharge.

Question 34

What is the CRUSADE score?

Answer 34

A score used to calculate major bleeding risk in patients suffering from NSTEMI and ACS conditions.

Question 35

What is the HEART score?

Answer 35

A diagnostic tool that helps doctors identify people at risk of major cardiac events; it combines info from medical history, ECG results and troponin levels to achieve an overall score.

Question 36

What are the diagnostic classifications of angina based on the features the NICE guidelines provide for typical angina chest pain?

Answer 36

Patient has 3 features - typical angina
Patient has 2 features - atypical angina
Patient has 1 or no features - non-angina, test