Chest Pain Flashcards
What are some examples of chest pain causes stemming from the cardiovascular disease?
Cardiovascular system
1. Ischaemic heart disease
2. Pericarditis
3. Aortic dissection
4. Myocarditis
What are some examples of chest pain causes stemming from the respiratory system?
Respiratory
1. Pneumothorax
2. Pneumonia
3. Pulmonary embolus
4. Pleurisy
What are some examples of chest pain causes stemming from the muscloskeletal system?
Musculoskeletal system
1. Muscle strain
2. Rib fracture
3. Costochondritis
4. Myositis
What are some examples of chest pain causes stemming from the gastrointestinal system?
Gastrointestinal system
- Oesophageal reflux
- Peptic ulcer
- Pancreatitis
- Gallstones
What are some examples of chest pain causes stemming from the nervous system?
Nervous system
1. Neuropathic pain
2. Shingles
3. Anxiety
When it comes to chest pain originating from a problem in the respiratory system, what signs should you look out for?
When it comes to chest pain originating from a problem in the gastrointesinal tract, what signs should you look out for?
When it comes to chest pain originating from a problem in the musculoskeletal system, what signs should you look out for?
When it comes to chest pain originating from a problem in the nervous system, what signs should you look out for?
Shingles – virus lives in the nerve endings of the spine – present in a dermatomal distribution
Chest pain can arise prior to skin rash appearing
What is the underlying pathology seen in ischaemic heart disease?
Narrowing of the blood vessels due to a build-up of fatty substance in arteries– happens over years and years
What are the different presentations of ischaemic heart disease?
- Stable Angina
- Unstable Angina
- Acute MI
What is angina? How does it present? How is the associated chest pain releived?
Angina - mis-match between oxygen supply and delivery in the heart
Chest tightness/pain/discomfort that occurs on excursion
Often worse in cold weather/walking into the wind
Location: central chest/radiate to throat/arm/back
Relieved by….
1. Resting
2. Sublingual glyceryl trinitrate (GTN) spray (can also be used as a diagnostic tool)
What investigations should be performed on someone that is suspected to have angina?
- Blood Tests
- 12 Lead ECG
- CT coronary angiography
- Alternatives
Image of CT-coronary angiography - stenosis/angina.
How are angina patients managed/treated?
Intensive lifestyle intervention
- Stop smoking, weight loss, exercise, diet- Mediteranean
Drug therapy
1. Sub-lingual GTN spray for symptomatic relief during an anginal episode
2. Aspirin (antiplatelet)
3. Beta-blockers (slows the heart rate, reduced myocardial O2 demands)
4. Calcium channel antagonists (coronary vasodilator)
5. Atorvastatin (reduces cholesterol)
6. Treat blood pressure-ACE inhibitor/Angiotensin receptor blocker - vasodilation and reduce fluid retnetion
What is acute coronary syndrome? How does it present?
Previously stable coronary heart disease becoming unstable - this can be either unstable angina or acute myocardial infarction
Chest Pain Presentation
1. Gradual or sudden onset
2. Tightness, pressure, crushing, band-like, weight on the chest
3. Comes at rest, minimal exertion, more intense exertion
4. Radiation to neck, jaw, arms
5. Usually lasts more than 15-20 minutes
6. No relationship with posture
Visceral pain - Nausea, vomiting, sweating, breathlessness
Risk factors - smoker, diabetes, hypertension, hypercholesterolaemia, family history of IHD/stroke/premature death of a parent
What investigations are performed when someone is suspected of having acute coronary syndrome?
12 Lead ECG
- May be diagnostic - ST segment changes
- ST elevation myocardial infarction (STEMI)
- Non-ST elevation myocardial infarction (NSTEMI)
Serum highly-sensitive troponin - Indicates myocardial necrosis/cell death
What leads are associated with infarctions in the following coronary arteries:
1. LAD - Left anterior descending coronary artery
2. LCx - left circumflex coronary artery
3. RCA – right coronary artery
- LAD - Left anterior descending coronary artery - Leads = V1-V4
- LCx - left circumflex coronary artery - Leads = 1, aVL, V5 and V6
- RCA – right coronary artery - Leads = 2, 3 and aVF
Knowing this we can localise the location of the occlusion
What does ST elevation indicate?
ST elevation indicates the presence of a myocardial infarction
These ECG changes persist over time - T wave inversion and ultimately the presence of a Q wave
Is it possible to have an non-ST elevation myocardial infarction?
Yes, non-ST elevation makes up the majority of heart attacks that present - ~80%
Non ST-elevation MI – depression of ST segment or Inversion of T wave wave in two anatomically contiguous leads
How is a non-ST Elevation MI (NSTEMI) diagnosed?
No ST elevation, chest pain and high troponin – Non-ST elevation MI (NSTEMI)
Difference between STEMI and NSTEMI in terms of pathology?
ST elevation represents – complete occlusion of a coronary artery
Non-ST elevation – caused by a block in a minor artery or a partial obstruction in a major artery.
What do these two ECGs show? How should these patients be managed/treated?
STEMI – occlusion of the right coronary artery – inferior STEMI – ST elevation in leads II, III and aVF – Requires to open artery with a catheter – has to happen in 2 hours
NSTEMI – ST depression in II, III, aVF, aVL and V6 - Inferior and lateral ischemia – NSTEMI – put into hospital – get angiogram within 2-3 days – treat drugs and put a stent in to reopen
How is acute coronary syndrome managed?
Management
1. Rapid diagnosis by ECG in the ambulance
2. Refer to a Specialist Cardiology service
3. Pain relief with morphine/opiate
4. Start oral aspirin and clopidogrel (Dual anti-platelet therapy)
4. Parenteral anticoagulation (IV or subcutaneous) – heparin, LMWH, factor Xa inhibitor
5. Oral or IV betablocker - reduce demand on heart
What are 6 different things that can be done to minimise future/secondary MI/strokes?
- Aspirin/clopidogrel – anti-platelet
- Beta-blocker
- ACE inhibitor/Angiotensin receptor blocker
- High dose atorvastatin (regardless of baseline cholesterol) - statin
- Treat diabetes if present
- Life-style intervention – smoking cessation, diet, exercise
What is pericarditis?
Pericarditis - inflammation of the pericardium (sac that contains the heart)
Occurs in younger people
None of the major risk factors but it is associated with a recent viral infection
What is pericarditis normally associated caused by?
Most commonly due to:
1. Viral infection including COVID
2. Autoimmune disease
3. Post-myocardial infarction
4. Post cardiac surgery
5. Pneumonia/pleurisy
What is pericarditis normally associated caused by?
Most commonly due to:
1. Viral infection including COVID
2. Autoimmune disease
3. Post-myocardial infarction
4. Post cardiac surgery
5. Pneumonia/pleurisy
How does pericarditis normally present?
Younger people with no or few cardiovascular risk factors, recent viral illness (respiratory/diarrhoeal)
Presentation
Chest pain
1. Central pain
2. Relieved by leaning forward
3. May be worse with respiration i.e. pleuritic
Cardiac examination
1. Pericardial friction rub- to and fro’ rubbing sound synchronous with systole and diastole
ECG
1. Widespread ST segment elevation (concave upwards) and PR depression
What does the ECG for pericarditis look like?
ECG can look like a heart attack
Widespread ST segment elevation (concave upwards) and PR depression
But…
- Widespread nature and non-classical pattern of coronary artery obstruction – indicative of pericarditis
- Also depression of the PR segment (lead II) – classic feature of pericarditis
What is aortic dissection? What patient typically presents with it?
Aorta made up of three layers – intima layer breaks – allowing blood to accumulate in between layers creating a true and a false lumen
Tends to occur in people with high blood pressure (mechanical disruption) and in young patients with inherited predisposition of aortic dissection – typically Marfan’s syndrome, rarer EDS and loeys dietz and loeys dietz
What are the common symptoms/examinations associated with aortic dissection?
Acute, severe chest pain
1. Pain knife-like, tearing,
2. Radiating through to the back between the shoulder blades
- Early diagnosis critical for survival
Examination
- Assymetric pulses - May lose pulses in arms or have different blood pressure between arms
