Chest Pain Flashcards
What is the DDx of Chest Pain?
Ones that can kill you:
Angina/MI
PE
Aortic Dissection
Myocarditis
Pneumothorax
Pericarditis
You’re fine:
GORD
PUD
Oesophageal spasm
Pneumonia/pleurisy
MSK pain, costochondritis
How do you take the Hx of chest pain?
Onset
Duration
Character:
- Location- central
- Radiation- arm, back, jaw
- Sharp vs heavy (cardiac)
- Pleuritic (worse on inspiration)
- Positional (pericardic = worse on lying)
- Exertional vs non-exertional
- Tearing through to back (aortic dissection)
Associated symptoms: nausea, diaphoresis, SOB
What more focused questions are you doing for the Hx of chest pain?
Recent febrile illness?
Thinking cardiac:
- RFs: HTN, dyslipidemia, FHx, male
Thinking PE:
- Recent surgery
- Recent immobility
-Active cancer
- Thrombophilia
- Sx of DVT
Thinking aortic:
- Known bicuspid aortic valve
- Marfan’s
- HTN
- FamHx of dissection
If you think cardiac and suspect they will need an angiogram what other questions should you ask?
- Chronic renal failure (contrast)
- Prior aortic issues: dissection, stenting, PVD
- Bleeding problems: malignancy, cirrhosis with esophageal varices
- On anticoagulant?
What do you do on Ex of a patient with chest pain?
Gen ob
Obs: pulses, BP (both arms- aortic dissection), O2
Auscultation:
- Murmur
- Crackles
- Absent or reduced breath sounds (pneumothorax)
- Hyperresonant percussion note
What bedside tests do you do for chest pain presentation?
ECG
What blood tests do you do for chest pain presentation?
- FBC: are they anaemic (type 2 ischaemia)
- Renal function: relevant for contrast
- Coagulation screen: need prior to procedure but also if PE
- Troponin (will need two)
- D-dimer (PE)
What are the considerations when doing trop on a patient presenting with chest pain?
- Standard troponin needs 10-12hr for exclusion of MI
- High sensitivity trop (HS-trop) can exclude in 4-6hrs but is less specific for ACS
If a patient presents after 6 hours of chest pain do you still do a repeat trop if the first was elevated?
No
What other conditions besides MI can cause an elevated HS-trop?
Heart failure
Sepsis (can get T2MI from sepsis)
Pneumonia
PE
Trauma
Renal failure
What imaging should be done on a patient presenting with chest pain?
CXR
CT aorta if suspect aortic dissection
Overall summary of the Ix you do when someone presents with chest pain
Bedside:
ECG
Labs:
FBC: anaemia (TIIMI)
UEC: renal function for contrast
Coags (before procedures + in setting of PE)
Troponin (likely need sequential)
D-dimer
Imaging:
- CXR
- CT aorta if suspect aortic dissection
What is the immediate treatment of an MI? (hint-mnemonic)
MONA
Morphine
Oxygen (only if hypoxic)
Nitrates for pain
Anti-platelet: aspirin
Anti-coagulate: 1 agent for STEMI (so you can operate), 2 agents for NSTEMI
Heparin given if it’s a STEMI = URGENT REPERFUSION and heparin is easier to reverse than clexane
Why does a STEMI get ST elevation?
ST elevation represents ongoing myonecrosis
- ST elevation correlates with total or subtotal obstruction of a major coronary artery
How do you manage a STEMI?
Still MONA for immediate Mx
Unblocking the artery depends on the location:
- Urgent angiogram and stenting/ PCI (percutaneous coronary intervention) = 1st line
- Otherwise if more rural for example you do thrombolysis
Thrombolysis: if no access to stenting
- Give as early as possible
- Alteplase
- Also give antiplatelet or anticoagulant (e.g. heparin, clexane)
When is thrombolysis contraindicated for the treatment of a STEMI?
With active bleeding, recent surgery, previous ICH, uncontrolled HTN
Relatively contraindicated with anticoagulation, previous CVA, PUD
Why is primary PCI the preferred intervention for a STEMI?
- Superior to thrombolysis, particularly later during MI
- Less risk of ICH
- Few absolute contraindications
What can an NSTEMI look like on ECG?
t wave inversion
How do you manage an NSTEMI?
Still MONA for immediate management but:
A: antiplatelets, give two agents instead of 1
Heparin or Clexane
Because they’re stable, they can have an angio on the next elective list (unless further ECG changes, worsening pain etc)
What are the considerations for angiography with an NSTEMI?
- Early invasive approach does improve outcomes
- So do angio when next available, not emergent
- Still perform revascularisation
After an ACS what long term treatment will they need?
DAPT: aspirin + ADP antagonist
Need it for 12 months even if they didn’t have a stent
Duration determined largely by the presence of a DES (drug eluting stent)
Do you give statins in ACS?
Yes- high dose of potent statin has early and late benefits independent of lipid profile
Intensify statin if already taking
Do you give B-blockers after ACS?
Generally start a Bblocker after an MI ESPECIALLY if LV impairment or residual CAD. But drug of choice is ACEI/ARB
If they’re normotensive with limited MI and a complete revascularisation then they may not need it
What is the drug of choice for HTN patients with CAD after an MI?
ACEI and ARBS
Especially if LV impairment, DM, CKD
Can have cardioprotective effects alongside BP lowering
If someone presents with tearing chest pain radiating to the back AND neuro symptoms what do you suspect?
Aortic dissection that is affecting the common carotid
What is the aetiology of aortic dissection?
- Most are degeneration (athero RFs)
- Presence of other aneurysms
- Chest trauma: most likely to cause a pseudoaneurysm
- Aortitis: syphilis, HIV, TB
- Inflammatory disorders: GCA, Takayasu
- CT disorders: Marfan’s disease
What are the types of aortic dissections?
Type A: ascending aorta. can extend distally. Surgery often indicated
Type B: involves the aorta beyond the left subclavian artery. often medically managed with BP control
What is the pathogenesis of aortic dissections:
Blood enters the media in one of the following ways:
1. Atherosclerotic ulcer leading to intimal tear
2. Disruption of the vasa vasorum causing an intramural haematoma
3. De novo intimal tear
Following the dissection, blood flow into the media may cause:
- Extension
- Rupture
- Vessel branch occlusion
- Aortic regurgitation
- Pericardial effusion/tamponande
How do you manage an aortic dissection?
Resuscitation: IV access, cross match blood
Control BP
Call vascular surgeons
What are the spot diagnosis features of Turner’s syndrome?
Webbed neck
Short stature
Heart defects
Delayed puberty
Reminder: turner’s is when a female is born with only one X Chr
What are the spot diagnosis features of Marfan’s syndrome?
Long arms
What do you do when you suspect a PE?
Well’s Score
If likely, do a D-dimer
What are the ECG findings of someone with a PE?
S1Q3T3
BUT most common is just sinus tachycardia
What is the characteristic finding of a PE on CXR?
Wedge shaped infarct
What are the ECG findings of pericarditis?
Widespread ST elevation
Saddle shaped t waves
How do you manage pericarditis?
Colchicine
PRN Ibuprofen
What is the typical clinical presentation of pericarditis?
Recent flu illness
Sharp chest pain
Worse lying flat
Eased leaning forward
Increased trop and increased CRP
