Chest Pain

Question 1

What are the cardiovascular causes of chest pain?

Answer 1

Non-ischaemic:

• Aortic dissection (tearing pain of very sudden onset)
• Pericarditis (retrosternal, relieved by sitting forward)

Ischaemic:

• CAD - angina, MIs
• Other causes:
  
  • Aortic stenosis → palpatiations, angina
  • HOCM (hypertrophic cardiomyopathy)
  • Tachyarrythmias
  • Cocaine use
  • Anaemia
  • Thyroxicity

Question 2

What are the non-cardiac causes of chest pain?

Answer 2

Upper GI:

• GORD
• gallstones
• peptic/duodenal ulcer

Respiratory:

• PE
• pneumothorax
• pneumonia
• pleurisy

Musculoskeletal:

• costochondritis
• herpes zoster

Question 3

What are the 3 criteria for stable / typical angina?

Answer 3

1. Substernal chest pain of characteristic quality and duration - i.e. tightness, heaviness, radiating, brief duration, gradual in onset/offset
2. Provoked by emotional / physical stress.
3. Releived by rest / GTN spray - a heart attack will not be releived by GTN; an artery is occluded completely.

Question 4

What are the characteristics of unstable angina?

Answer 4

• Occurs randomly at rest; most commonly at night
• No clear trigger
• Crescendo pattern: happens once, then is worse the next time etc.

The blockage in the artery is itself moving / possibly sending out little clots; this is what makes it unstable. Heart attack could occur soon! Hence this is classified as an ACS.

Question 5

Name as many risk factors for CAD as possible

Answer 5

• Age (older ↑risk)
• Male
• DM
• Hyperlipidaemia
• Smoking
• HTN
• Stress
• Alcohol
• Poor diet
• Overweight
• Poor mental health

Question 6

Describe to a patient what to do if they have an attack of stable angina.

Answer 6

1. Spray your GTN spray (under your tongue)
2. Wait 5 minutes
3. Spray again if still in pain
4. Wait another 5 minutes
5. If the pain is still there, call 999

OSCE possibility: “Can I take the spray before I do exercise, Doctor?”

You can also use GTN to avoid an attack before doing exercise. Explain that the patient may have a headache, flushing or dizziness soon after using it.

Question 7

What is atypical angina?

Answer 7

Angina that has only 2 of the 3 Typical Angina symptoms:

1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2. precipitated by physical exertion
3. relieved by rest or GTN within about 5 minutes.

Question 8

What is the initial drug therapy for all ACS patients (STEMIs, NSTEMIs and unstable angina)?

What investigation follows?

Answer 8

1. Aspirin 300mg
2. Nitrates (sublingual or IV - watch out if they are hypotensive)
3. +/- morphine for severe pain
4. +/- oxygen for sats <94%

ECG! They may be eligible for PCI or finbrinolysis

Question 9

What are the troponin levels in a:

1. Possible MI
2. Probable MI?

Answer 9

1. Possible MI: 14-30ng/L
2. Probable MI: >30ng/L

Question 10

What are abnormal Q waves and what do they show?

Answer 10

• Abnormal Q waves are >1 small square wide or >2mm deep
• They are the result of a patch of cardiac muscle dying, creating an electrical window to the other side.
• Indicate MI

Question 11

Which limb leads are in which axis?

Answer 11

Question 12

What other 3 parts of the history are relevant to diagnosing coronary artery disease?

Answer 12

1. Con-current diagnosis of coronary artery disease (e.g. stable angina, previous myocardial infarction).
2. Con-current diagnosis of other atherosclerotic arterial disease – (e.g. ischaemic stroke, peripheral vascular disease, renovascular disease).
3. Family history of coronary artery disease or atherosclerotic arterial disease.

Question 13

Although coronary artery disease (CAD) cannot be excluded based on a normal ECG there are some changes which indicate CAD is highly likely to be present. What are these?

Answer 13

1. Pathological Q waves usually indicate current or prior myocardial infarction. Q waves are considered pathological if:

• > 40 ms (1 mm) wide
• > 2 mm deep
• > 25% of depth of QRS complex
• Seen in leads V1-3

2. Left bundle branch block (LBBB). ECG characteristics of LBBB are:

• Broad QRS (>3small square/0.12sec) and
• Deep S wave in V1 and
• No Q wave in V5/V6

3. ST segment and T wave abnormalities (e.g. ST segment depression or T wave flattening or inversion)

Question 14

Does a normal ECG exclude ACS?

Answer 14

No!

Question 15

What is the immedicate drug treatment for ACS?

Answer 15

1. Loading dose of aspirin = 300mg, later ↓to 75mg
2. +/- antiplatelet e.g. clopidogrel 300mg loading dose, later ↓to 75mg

Question 16

What test is used to differentiate unstable angina from myocardial infarction?

Answer 16

A high-sensitivity blood test for serum troponin — cardiac troponin I and T are used to differentiate unstable angina from myocardial infarction.

• A detectable troponin level indicates damage to the myocardium (for example myocardial infarction).
• Serum troponin is normally detectable using high-sensitivity testing within 3–6 hours following a myocardial infarction, and remains elevated for a variable time (usually several days, but it can be up to 2 weeks).
• Other conditions that directly or indirectly damage heart muscle (such as arrhythmias, pericarditis, pulmonary emboli, and myocarditis) can also cause an increase in serum troponin.

Question 17

What does cardiac rehab involve?

Answer 17

• education
  
  • lifestyle:
    
    • diet
    • exercise
    • alcohol
    • smoking
    • weight loss
• exercise
• stress management
• drug therapy

Question 18

What conditions do you have to tell the DVLA about?

Answer 18

All about loss of consciousness!

• diabetes or taking insulin → hypoglycaemia
• syncope
• heart conditions (including atrial fibrillation and pacemakers) → syncope
• sleep apnoea
• epilepsy
• strokes
• glaucoma

Cardiovascular disorders:

• 1 week off after angioplasty or pacemaker insertion
• 4 weeks off after ACS, CABG
• ICD - depends on cause (6 months if ventricular arrythmia, 1 month if prophylactic)
• Cannot drive if:
  
  • angina at rest
  • aortic aneurysm 6.5cm or more

Question 19

What are the ECG criteria to diagnose a ST elevation MI?

Answer 19

ECG features in ≥ 2 contiguous leads of:

• 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
• 1.5 mm ST elevation in V2-3 in women
• 1 mm ST elevation in other leads
• new LBBB (LBBB should be considered new unless there is evidence otherwise)

Question 20

Describe aortic stenosis murmur

Answer 20

Ejection systolic murmur heard loudest in the aortic area radiating to the carotids.

Question 21

Describe Aortic regurgitation murmur

Answer 21

Early diastolic murmur heard best at the left 4th intercostal space with the patient sat forward in expiration.

Question 22

Describe Mitral Stenosis murmur

Answer 22

Mid-diastolic rumbling murmur, heard best with the bell of the stethoscope at the apex with the patient in the left lateral position.

Question 23

Describe Mitral Regurgitation murmur

Answer 23

Pansystolic murmur heard loudest at the apex of the heart radiating to axilla.

Question 24

What drugs are most ACS patients given longterm after an event? x5

Answer 24

1. Aspirin, 75mg lifelong
2. Another antiplatelet if appropriate e.g. clopidogrel, 6-12 months
3. Statin, lifelong
4. ß-blocker, lifelong
5. ACE-I, lifelong

Question 25

Describe the ECG changes that occur as a patient progresses through an MI

Answer 25

1. hyperacute T waves are often the first sign of MI but often only persists for a few minutes
2. ST elevation may then develop
3. the T waves typically become inverted within the first 24 hours. The inversion of the T waves can last for days to months
4. pathological Q waves develop after several hours to days. This change usually persists indefinitely