Chest pain

Question 1

What are the three most common causes of chest pain?

And how often is the cause cardiac?

Answer 1

1. Musculoskeletal
2. Costochondritis
3. Respiratory

0-5%

Question 2

What features are reassuring for non cardiac cause of chest pain?

(And when to refer)

Answer 2

1. Non exertional chest pain
2. Negative FHx (LQTS, cardiomyopathies, sudden death)
3. No hx of Kawasaki or heart disease
4. Normal cardiac examination (specifically no pathological murmur)
5. Normal ECG and CXR

Question 3

What is the definition of syncope, and how does it differ from presyncope

Answer 3

Syncope is the transient loss of consciousness and muscle tone from inadequate cerebral perfusion.

Presyncope- remain conscious, and mostly benign

Question 4

What is the difference between vasovagal and orthostatic hypotension

Answer 4

Vasovagal episodes have prodrome of dizziness, nausea, pallor, sweating, palpitations, blurry vision.

Sudden drop in HR and BP- withdrawal of sympathetic activity and vagal activation

Orthostatic hypotension: abscence of normal reflexic adrenergic vasoconstriction

Only dizzyness

Usually related to medication, dehydration, bed rest, dysautonomia GBS

Question 5

What are the cardiac causes of syncope?

Answer 5

1. Arrhythma
   
   1. Tachycardia:SVT, AF, VT (LQTS, WPW, Brugada)
   2. Bradycardia: Sinus, asystole, heart blosck, pacemaker malfunction
2. Obstructive lesions
   
   1. Outflow: AS, PS, HOCM, Pulmonary HTN
   2. Inflow: MS, tamponade, constrictive pericarditis, atrial myxoma
3. Myocardia
   
   1. Coronary artery anomalies
   2. HOCM
   3. Dilated CMP
   4. MVP
   5. Arrhythmogenic RV dysplasia

Question 6

What are important history features of syncope?

Answer 6

1. The event
   
   1. Time of day
   2. Position (sitting/lying ?cardiac, sz)
   3. ?exercising
   4. Associated palpitations, chest pain, nausea, headache
   5. Duration (<1 min- vasovagal, orthostatic, hyperventilation)
2. Cardiac, endocrine, neurological, psychological conditions
3. Medications
4. Family history
   
   1. Coronary heart disease risk factors
   2. Arrythmias, CHD, CMP, LQTS, Sz
   3. Fainting?
5. Social history
   
   1. Substance abuse, pregancy, ?conversion

Question 7

What investigations are helpful in syncope?

Answer 7

1. BGL and UEC limited value hours after event
2. ECG/Holter/stress ECG
3. ECHO
4. Head up tilt table test (if autonomic symptoms)
   
   1. Vasovagal- abrupt decrease in BP
   2. Dysautonomia- gradual decrease in BP leading to syncope
   3. POTS: Excessive HR increase to maintain adequate BP
5. Electrophysiological testing
6. Neurology consult if seizure suggestive