Central Chest Pain Flashcards
If chest pain is of a constricting nature, what are the likely differentials?
Angina
Oesophageal spasm
Anxiety
If chest pain radiates to the shoulder, arms, or neck/jaw what is a likely differential?
Cardiac ischaemia
What is the characteristic pain presentation of aortic dissection?
Instantaneous, tearing and inter scapular
How does pericarditis pain improve?
Leaning forward
What conditions can cause angina?
Coronary artery disease
Cardiomyopathy
Aortic stenosis
Can be exacerbated by anaemia
What does chest pain with tenderness suggest?
Self-limiting Tietzes syndrome (benign inflammation of costal cartilages)
If there is pain on respiration, exacerbated by gentle pressure on the sternum, what does this indicate?
Fractured rib
If BP is unequal in both arms, what condition does this point towards?
Aortic dissection
What pathologies can cause palpitations?
Ectopics Sinus tachycardia AF SVT and VT Thyrotoxicosis Anxiety Phaeochromocytoma
What are the cardiovascular causes of chest pain?
Angina
MI
Pericarditis
Dissecting AA
What are the pulmonary causes of chest pain?
Tracheobronchitis (on either side of the sternum there is burning pain, exacerbated by coughing, relieved by lying)
Pleurisy
Pneumonia
Both of the above present as sharp and knife-like
What are the GI causes of chest pain?
GORD
Oesophageal spasm
What is the pre-hospital management of an acute MI?
MONA Morphine Oxygen (if <94% sats) GTN 300mg aspirin
What is the in-hospital management of a STEMI?
Aspirin, antiplatelet (ticagrelor/prasugrel) and LMWH (enoxaparin) prior to PCI
PCI if it can be delivered <120 hours and <12 hours before the onset of chest pain
OTHERWISE
Fibrinolysis and check ECG after 90 minutes
If no resolution, angiography and follow on PCI
What is the in-hospital management of a NSTEMI?
Give clopidogrel Give antithrombin (unless if at a bleeding risk) Use the GRACE score to predict mortality
If there is a high risk of mortality, angiography <96hours with a GIIb/IIIa receptor antagonist (eptifibatide)
What are the conservative, medical and surgical management strategies for someone with chronic ACS?
Conservative: lifestyle factors, cardiac rehabilitation programmes, is bus/lorry inform DVLA
Medical: 5 A’s. Aspirin, Antiplatelet, ACE, Atenolol, Atorvastatin
Surgical: coronary artery bypass graft
What drug can cause an oculogyric crisis and what drug can be used to treat this?
Metoclopramide
Procyclidine
What is Dressler’s syndrome and what do the investigations of it show?
A subtype of pericarditis
Immune response after trauma to the heart tissue or pericardium
Seen 2-6 weeks post MI sometimes
Raised ESR, pleuritic chest pain, pericardial rub, ST elevation
Use NSAIDs to treat
How does a left ventricular aneurysm present?
Can be 4-6 weeks post MI. Due to weakening of the myocardium.
Presents with pulmonary oedema and ST elevation in anterior leads. A thrombus may form within the aneurysm. This can lead to a stroke
Anticoagulate
How does post-MI cardiac tamponade present and what is the management?
Beck’s triad: hypotension, raised JVP, muffled heart sounds
Pulsus paradoxus present
Use pericardiocentesis to manage
What tests do you do in suspected ACS?
ECG
CXR: look for cardiomegaly, pulmonary oedema
Bloods: FBC, U&E, glucose, lipids, cardiac enzymes
Outline the cardiac enzymes
Myoglobin is the first to rise
Troponins I and T are the most specific to the heart and myocardial damage (can also be raised with other things)
CK, CK-MB and AST also raised in response to a MI. CK-MB is useful to look for reinfarction as it returns to normal after 2-3 days
What are the CI to thrombolysis in patients with ACS?
Previous intracranial haemorrhage
Ischaemic stroke <6m
Cerebral malignancy
Aortic dissection
What is the long term pharmacological management of someone who presents with ACS?
2 antiplatelets: aspirin and clopidogrel for 12m
Anticoagulate with fondaparinux until discharge
Beta blocker: reduces myocardial oxygen demand
ACEi in patients with hypertension or diabetes
Atorvastatin 80mg
Which patients must receive a CT angiography?
STEMI patients and very high risk NSTEMI patients (GRACE >120) should receive angiography and/or PCI.
What driving advice do you give to patients who have had an ACS?
Driving: Group 1: can resume driving 1wk after successful angioplasty, or 4wks after ACS without successful angioplasty.
Group 2: must inform the DVLA and stop driving. May be able to start after 6 weeks.
What is the emergency management of a pulmonary embolus?
1) If hypoxic, oxygen 10-15L/min
2) Morphine 5-10mg IV with metoclopramide
3) LMWH/Fondaparinux
4) If decreased BP give 500mL bolus
5)
If haemodynamically stable, LMWH
If hypotensive, thrombolyse (alteplase)
If haemodynamically unstable, give dobutamine or noradrenaline
6) Long term anticoagulation
What are the investigations for a PE?
ECG (see other flashcard for signs)
CXR
ABG (hyperventilation)
Serum D dimer (low specificity, can be increased by thrombosis, inflammation, infection and malignancy)
CTPA (gold standard). If unavailable, do a V/Q scan
Outline what happens in a thoracic aortic dissection and the signs of it
Blood splits the aortic media with sudden tearing chest pain and radiation to back.
Hemiplegia, unequal arm pulses, acute limb ischaemia, paraplegia,
Type A: ascending aorta (70%). SURGERY.
Type B: anywhere else.
What is the emergency management of an aortic dissection?
Crossmatch 10u blood.
ECG, CXR
CT or TOE
Hypotensives: keep systolic at 100-110. Labetalol.
What are the indications for a CABG?
How does a CABG work?
Left main stem disease or triple vessel disease
Angina unresponsive to drugs
Unstable angina
If angioplasty is unsuccessful
The patients own saphenous vein or internal mammary artery are used as the graft. Cardiac bypass surgery needed.
If you have a strong suspicion that a patient has a PE but there is a delay in the CTPA occurring, what do you do?
Give LMWH while waiting for the scan
If a patient has a PE and renal impairment, what is the most appropriate initial investigation?
Ventilation perfusion scan
