Chest Pain Flashcards
What are the main causes of acute chest pain?
- Musculoskeletal inflammation
- Acute coronary syndrome
- Pulmonary Embolism (PE)
- Stable Angina
- Pleurisy (second to infection)
- Oseophagitis (secondary to gord or hiatus hernia)
- Pneumothorax
- Anxiety
- Peptic ulcer disease or gastritis
- Myopericarditis (including stress induced (Takotsubo) cardiomyopathy)
- Cholecysitis
- Acute pancreatitis
- Thoracic aortic dissection
- Thoracic aortic aneurysm
- Coronary vasospasm (secondary to cocaine)
- Oesophageal spasm
- Boehavaves perforation of the oesophagus
What are some disease of old age related to chest pain (check age!)?
- Acute coronary syndrome
- Stable angina
- Myopericarditis (post infarction)
- Thoracic aortic dissection
- Thoracic aortic aneurysm
What are some disease of young age with oral combined pill related to chest pain?
- PE
- Pneumothorax (esp if tall and thin)
- Cocaine induced coronary spasm (rare but very unusal in older people)
What chest pain differentials are fatal and require immediate management
- Acute coronary syndrome (unstable angina or MI)
- Aortic dissection
- Pneumothorax
- PE
- Boerhaave’s perforation
What would the history of acute coronary syndrome sound like?
- Sudden onset
- Central crushing pain
- radiating arms neck or jaw
- few mins-30 (longer if MI)
- Esp if previous history
What are signs of hypercholestroleamia?
- Xanthomata
- Xanthelasma
- Arcus (normal in older people)
What are the signs of peirpheral (atheroscelortic) vascular disease?
- weak pulses
- peripheral cyanosis
- cool peripheries
- atrophic skin
- ulcers
- bruits on auscultation of caortids
Why is it important to look out for arrthymias with chest pain?
- Can be cause of ischaemia as both can cause decrease in cardiac output and so reduced cardiac perfusion and so ischaemia
- Arrythmias most commonly arise in scarred myocardium, both from old infarcts and sometimes following an acute infarct (e.g. heart block or ventricular tachycardia)
What is the history of someone with an aortic dissection?
- Sudden onset
- tearing chest pain
- radiating to back
- pain most intense from the very onset
What are the signs of someone with an aortic dissection?
- Absent pulse in one arm
- Hypertension (50% of cases), Hypotension (25% of cases)
- A difference in BP between arms (more than >20mmHg) (33% of cases)
- New onset aortic regurgitation (manifesting as e.g. early diastolic murmur) -
- Pleural effusion usually on the left
What is the common medical history for someone with aortic dissection?
- hypertension
- smoking
- atheroscelrosis (e.g. previous PVD or IHD)
- recent aortic valve replacement
What is the history of someone with a pneuomthorax?
- Sudden onset
- pleuritic chest pain
- with breathlessness
- may also present as painless breathlessness
What are the signs of someone with a pneumothorax?
- Hyper-inflated chest wall with impaired expansion
- Hyper-resonant percussion over affected area
- Absent breath sounds over affected area
- Tracheal Deviation
Which way does the trachea deviate in tension pneumothroax?
AWAY from suspected pneumothorax
Why is a tension pneumothorax dangerous?
- flap of pleural membrane acts as a valve so that pleural space gets increasingly inflated with air
- eventually starts to deviate mediastium which can compress heart leading to cardiopulmonary arrest
What is the usual history of someone with a PE?
- Sudden onset SOB
- and/or pleuritic chest pain (66%)
- and/or haemopytsis (13%) in someone with an inflamed limb
- and/or risk factors for blood clots
What are the signs of someone with PE?
- Tachycardia: most common finding
- Signs of hypoxia (need a big one)
- PE should be considered when no other explanation of chest pain - WELLS CRITERIA
What would history of someone with Boehaave’s perforation be like?
- Sudden onset
- Severe chest pain immediately following vomit
- SOB and pleuritic pain
- Pleural effusion in hours
- Subcutaenous emphysema
- Abdominal rigidity, sweating, fever, tachycardia and hypotension often present as the illness progresses but are non-specific
What are signs of pleural effusion?
- dullness to percussion
- absent breath sounds
- decreased vocal resonance
What investigations do you do for chest pain?
- ECG
- Bloods
- Imaging (chest X ray)
- D-dimer
What are you looking for on ecg?
- signs of arrythmia or ischaemia
2. ST elevation and newt LBBB
What would you look for in an ECG or someone suspected PE?
right heart strain + tachycardia
What blood tests do you do for chest pain?
- Troponin
- CK-MB
- Serum cholesterol
- FBC
- U+Es
- Inflammatory markers
- Capillary glucose
- Amylase
When do you measure troponin?
- on admission and 3-12 hours from onset
- min 3 hours for increase
What is less specific than troponin?
CK-MB
When do CK-MB levels rise and fall?
- normal within 2-3 days and troponin levels remain high >7 days
- elevated more than 4 days suggest reinfarction
Why do you check serum cholesterol?
hypercholesterolaemia risk factor for CVD
How do MI affect LDL and HDL?
decrease in total LDL and HDL levels in about 24 hours and will return 2-3 months after
What are you look for on FBC?
anaemia
Why is anaemia important in chest pain?
exacerbate any deficiency in cardiac perfusion, resulting in IHD
What do you look for in U+Es?
potassium may be cause of arrythmia
What conditions may cause an elevated inflammatory processes (WCC+CRP)?
- pericarditis
- Bronholm’s disease
- Elevated following MI and aortic dissection
Why do you check cap glucose?
- increase in risk of CVD with DM particularly if untreated esp T2
- diabetic silent infaraction
Why do you check amylase
acute pancreatitis
Why do you do an erect chest xray?
- Pneumothroax
- Aortic pathology (aneurysm, dissection and giving a wide mediastinum) - Can have normal chest radiogrpah in aortic dissection
- Air in heart shadow, a pleural effusion and/or pneumothroax if Boerhaave’s!
What would give a wide mediastinum in a chest x ray?
- aneurysm
- dissection
What serious condition can have a normal x ray?
aortic dissection
What would air in heart shadow on chest xray suggest?
pleural effusion and/or pneumothroax if Boerhaave’s
What can low D-dimers rule out?
DVT or PE
Why do D-dimer elevate?
breakdown of a fibrin clot due to any cause such as recent surgery or trauma
What would High troponin and ST depression in leads V1-V3 suggest?
anterior NSTEMI
Can a posterior wall transmural infarction present with depressed ST leads V1-V3 but be a STEMI?
yes
What is the MONABASH treatment for acute coronary syndrome following ABC?
- Morphine
- Oxygen
- Nitrates
- Antiplatelets
- Beta blockers
- ACE-inhibitors
- Statins
- Heparin (LMWH)
Why do you give morphine?
analgesia + antiemeitc
When do you give oxygen?
if required in order to keep sats at 94%
What nitrates do you give and why?
e.g. GTN, isosorbide mononitrate infusion, for vasodilation
What antiplatelets do you give?
aspirin + ADP receptor blockers (clopidogrel, prasugrel, ticagrelor)
Why do you give beta blockers?
to reduce myocardial oxygen demand
When are beta-blockers contraindicated?
- heart block
- asthma
- acute heart failure
Why do you give ACE-inihibtiors?
- . attenuation of post-infarct ventricular remodelling that can cause arrhthymias
- reduction of angiotesin-II induced vasoconstriction improving cardiac blood flow and reducing after-load
- beneficial effects on endothelial function
Why do you give statins?
- reduce cholesterol level
- improve endothelial function
- modulate inflammatory response (reduce CRP)
maintain atherosclerotic plaque stability - prevent thrombus formation
Why do you give heparine?
prevent coronary thrombosis
What treatment do STEMI patients recieve?
primary angioplasty (better) or thrombolysis within 12 hours of the onset of pain - rapid treatment best
When do NSTEMI patient get primary angioplasty?
- haemodynamically unstable
- severe left ventricular dysfunction
- ongoing chest pain
- new mitral regurgitation
- ventral septal defect
- sustained ventricular arrhythmias
- GRACE score
What secondary preventions are used for NSTEMI and STEMI?
- Lifestyle changes
2. RF contol with medications
How would you control BP LT?
ACE inhibitors <55 and white or CCB or thiazdie diuretics if >55 and non-white
How would you control cholesterol LT?
statins or fibrates
What condition is important control LT?
DM
How do reduced thromboembolic risk LT?
low-dose aspirin for life and an ADP receptor inihibitor (e.g. clopidogrel, ticagrelor) for a period of 1 year
