CHEST PAIN

Question 1

What is the pathophysiology of an MI?

Answer 1

A myocardial infarction (MI) results when a blood clot completely obstructs a coronary artery supplying blood to the myocardium, causing ischaemia and necrosis. The blood clot that causes the myocardial infarction usually forms at the site of rupture of an atherosclerotic plaque on the inner wall of a coronary artery.

Question 2

what are the risk factors for an MI?

Answer 2

hypercholesterolaemia
hypertension
tobacco use
diabetes
sedentary lifestyle
male gender
genetics

Question 3

what are the symptoms of an MI?

Answer 3

arm or jaw pain
shortness of breath
nausea
general lethargy
diaphoresis
some patients may be asymptomatic

Question 4

what are the two types of MI?

Answer 4

STEMI and NSTEMI

Question 5

what is the difference between a STEMI and an NSTEMI?

Answer 5

STEMIs show ST elevation on an ECG
NSTEMIs don’t show ST elevation on an ECG. They are diagnosed in the hospital by measuring troponin T and I levels (cardiac enzymes).

Question 6

What is the pathophysiology of angina?

Answer 6

Angina is chest discomfort that occurs due to a decreased blood oxygen supply to an area of the heart muscle. The myocardium demands more oxygenated blood than the narrowed coronary arteries can deliver. In most cases, reduced blood supply is due to a narrowing of the coronary arteries resulting from arteriosclerosis. Consequently, angina can be caused by coronary artery disease or spasms of the coronary arteries.

Question 7

describe the three types of angina

Answer 7

Stable angina: The most common form of angina. Symptoms occur on a regular basis, generally caused by exertion, and only lasts for a few minutes. Symptoms are relieved at rest and/or with GTN.
Unstable angina: A less common and more serious form of angina. Symptoms are more severe and less predictable. Pain is more severe, lasts longer, occurs at rest, and is either not relieved with GTN or requires a larger amount for relief. This form of angina is often a precursor to an MI.
Prinzmetal’s angina: This is caused by a spasm in a coronary artery, temporarily decreasing blood supply to a section of the myocardium. It is rare and also unpredictable and may not be relieved with rest and medication.

Question 8

what can cause arrhythmias?

Answer 8

coronary heart disease (CHD)
electrolyte imbalances
chemicals in the blood
can be idiopathic in nature
certain medications or drugs

Question 9

what medications/drugs can cause arrhythmias?

Answer 9

appetite suppressants, Beta-blockers, caffeine, cocaine, amphetamines, nicotine, alcohol, positive chronotropic drugs and thyroid medications.

Question 10

what are some common symptoms of arrhythmias?

Answer 10

palpitations, chest pain, dizziness or syncope, diaphoresis, shortness of breath, light-headedness, fullness in the throat or neck, or generalised weakness.

Question 11

what are the important arrhythmias to be aware of?

Answer 11

tachyarrhythmias: SVT and VT
bradyarrhythmias: sick sinus syndrome (SSS) and AV blocks

Question 12

what is the pathophysiology of pericarditis?

Answer 12

Pericarditis is the inflammation of the pericardium (the sac-like membrane which surrounds the heart and protects it from overstretching). Most often the cause of pericarditis is unknown. However it may result from mechanical injury to the heart, viral or bacterial infections, tumors or cancer, connective tissue disease, metabolic diseases or reactions to medications.

Question 13

what are the symptoms of pericarditis?

Answer 13

The main symptom of pericarditis is chest pain (which is almost always present), which may be sharp in nature. Pain may radiate to the back, neck, arm or shoulder blade and can often be made worse with deep breathing or swallowing. The pain is usually positional and can often be made worse by lying flat and better when leaning forward. Other symptoms depend upon the specific cause of the pericarditis (e.g. infections may present with fever, muscle aches and malaise).

Question 14

What is a pre-hospital diagnostic tool to identify pericarditis?

Answer 14

Global ST-elevation on ECG

Question 15

what is the pathophysiology of an aortic dissection?

Answer 15

An aortic dissection results when a tear occurs in the inner muscle wall lining of the aorta, allowing blood to split the muscle layers of the aortic wall apart.

Question 16

what are the two types of aortic dissection?

Answer 16

type A (involving the ascending aorta) is treated surgically, type B is treated with medical management, with mortality being high for both types of aortic dissection. Reducing the risk factors for aortic dissection (such as high BP and cholesterol) are key to prevention of this condition.

Question 17

what are the symptoms of an aortic dissection?

Answer 17

Symptoms of aortic dissection include a tearing or ripping pain in the chest or back, sweating, nausea, shortness of breath, weakness, or syncope. The symptoms are mainly as a result of reduced blood flow to parts of the body. The patient will often present with different blood pressures on each side of the body, and signs of poor perfusion.

Question 18

what is the pathophysiology of a pulmonary embolism?

Answer 18

Pulmonary embolism occurs when a DVT breaks off and enters the circulatory system. It then enters the heart through the IVC, travels through the right atrium and ventricle, and exits the heart through the pulmonary artery. The embolus then becomes lodged in one or more pulmonary arteries. This not only prevents the exchange of oxygen and carbon dioxide in the lung, but also decreases blood supply to the lung tissue itself, potentially causing infarction.

Question 19

what are the risk factors for developing a pulmonary embolism (PE)?

Answer 19

The risk factors for a pulmonary embolism are the same as the risk factors for deep vein thrombosis. These are referred to as Virchow’s triad and include: prolonged immobilisation or alterations in normal blood flow, hypercoagulability (e.g. birth control pills, smoking, genetic predisposition, polycythaemia, pregnancy), any damage to the walls of the veins (e.g. prior deep venous thrombosis, trauma to the lower leg).

Question 20

what are the symptoms of a pulmonary embolism (PE)?

Answer 20

sudden onset of sharp chest pain that worsens with deep breathing, shortness of breath, cough (possibly with bloody sputum), changes in vital signs (often an elevated heart rate and respiratory rate, decreased blood pressure and reduced oxygen saturations if clot is large enough), light-headedness, generalised weakness and even cardiac arrest.

Question 21

what are the key indications of a pulmonary embolism (PE)?

Answer 21

Large emphasis on patient history and recent events (eg. recently travelling with long flights).
signs of DVT (red, swollen calf) and risk factors for blood clots

Question 22

what is the pathophysiology of gastro-oesophageal reflux disease (GORD)?

Answer 22

a condition in which the acidified liquid contents of the stomach moves up into the oesophagus.

Question 23

what are the common symptoms of GORD?

Answer 23

The symptoms of uncomplicated GORD are heartburn, regurgitation and nausea. People often experience an ‘indigestion’ type feeling, but often the presentation may change (or be the first presentation) and so they may think they are having a ‘heart attack’. Classically a patient will say that it is a burning sensation in the centre of their chest which is worse when lying down, and is often precipitated by a spicy/acidic meal.