Chest Pain Flashcards
What are the causes of chest pain?
- Cardiac (MI, angina, pericarditis)
- Vascular (aortic dissection)
- Respiratory (PE, pneumothorax, pleurisy)
- GI (Reflux, oesophageal tear)
- Neurological (herpes zoster)
- Musculoskeletal
What should be included in the history for a patient with chest pain?
- Presenting complaint
- Past medical history
- Drug history
- Family history
- Social history
What should the past medical history include?
- History of CHD
- Recent operations/procedures (e.g. cardio Sx)
- History of peptic ulcer disease or use of NSAID
- Recent illness - Pericarditis might be proceeded by prodromal viral illness
- Long periods of inactivity - May precede PE
- Hypertension
- Diabetes, high cholesterol
What should the drug, family & social history include?
- Risk factors for CHD (age, ethnicity, family Hx, smoking, obesity, physical inactivity, depression, stress)
- Heavy alcohol use (risk factor for gastritis & peptic ulcer disease)
What questions specifically regarding the chest pain should be asked?
- Duration of pain
- Site of pain
- Intensity of pain (VAS)
- Quality of pain (burning, dull etc)
- Continuous/intermittent
- Radiation of pain
- Experienced before
- Aggravating/easing factors
- Other symptoms at same time (nausea, SOB, sweating)
What does CVD include?
Heart, stroke and blood vessel diseases
What are the warning signs of a heart attack?
- Pain, pressure, heaviness or tightness in jaw, neck, shoulders, chest, back, arms
- Nausea
- Dizziness
- Cold sweat
- SOB
How are the heart attack signs different for women?
More than 40% don’t experience chest pain
What are the pain characteristics of myocardial ischaemia?
Quality: Crushing, tight Site: Central anterior chest Radiation: Throat, jaw, arms Agg: Exertion, anxiety, cold Eas: Rest, glyceryl trinitrate Associated: Sweaty, SOB, nausea, shocked
What is aortic dissection?
- Damage to layers of aorta
- High intraluminal pressure causes a tear
- Blood enters & dissects the luminal plane creating a false lumen
What is the primary risk factor for aortic dissection?
Hypertension
What are the signs of aortic dissection?
- Shock, cyanosis, sweating
- BP & pulses differ between extremities
- Aortic regurgitation, cardiac tamponade, cardiac failure
What is circulatory shock?
CV dysfunction, inadequate O2 being delivered to tissues
What are the types of causes of circulatory shock?
- Hypovolaemic
- Septic
- Cardiogenic
- Anaphylactic
- Spinal
- Neurogenic
- Toxic
What are the symptoms of aortic dissection?
- Central tearing chest pain radiating to back
- Further complications arise if dissection affects beaches of aorta (MI, hemiplegia, paraplegia, abdominal pain)
What are the aortic dissection investigations?
- CXR: widened mediastinum
- ECG: ST elevation
- CT/MRI: False lumen
- Echo: Pericardial effusion
What are the pain characteristics of aortic dissection?
Quality: Sharp, stabbing, tearing Site: Retrosternal, interscapular Radiation: Usually nil Agg/Eas: Nil (constant) Associated: Unequal pulse & BP, aortic regurgitant murmur
What are the pain characteristics of pericarditis?
Quality: Sharp, (may be crushing) Site: Central anterior Radiation: Usually nil Agg: Lying back Eas: Sitting forward Associated: Fever, recent viral illness
What are some of the causes of pericarditis?
- Viral illness
- Injury to the chest
- Cardiac surgery
- Heart attack
What are some of the respiratory causes of chest pain?
- Pleurisy
- PE
- Pneumothorax
- Tumours
What features are associated with respiratory causes of chest pain?
- Cough (may be productive)
- Haemoptysis
- Shock (PE)
- Dynpnoea
What are the causes of dyspnoea?
- Cardiac failure
- Coronary artery disease
- Pulmonary embolism
- Pneumothorax
- COPD, asthma
What chronic dyspnoea signs are associated with heart failure?
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
What acute dyspnoea signs are associated with heart failure?
- Crackles/wheezes
- Pink, frothy sputum
- APO
- Pneumothorax
- PE
What are the outcomes of right and left sided heart failure?
Right: Peripheral oedema
Left: Pulmonary oedema
What are the pain characteristics of GI causes of chest pain?
Quality: Burning
Site: Central
Radiation: To throat
Agg: Food (oesophageal pain & cholecystits)
Eas: Food & antacids (peptic uler pain)
Associated: Excessive wind
What are the likely causes of musculoskeletal chest pain?
- Rib trauma (fracture, contusion)
- Referred pain from TS
- Sternoclavicular joint disorders
What are the less likely causes of musculoskeletal chest pain?
- Costochondritis
- Sternocostal joint sprain
- Intercostal muscle sprain
- Rib stress fracture
- Fractured sternum
What are the NTBM causes of musculoskeletal chest pain?
- Cardiac causes
- Peptic ulceration
- GI reflux
- Pneumothorax
- PE
- Herpes zoster
What is herpes zoster?
- Reactivation of varicella zoster virus (chicken pox) in sensory ganglion
- Extremely painful
- Symptoms: Headache, fever, malaise, followed by itching, tingling, pain with dermotomal distribution, rash
What factors differentiate chest pain referred from TS, rather than myocardial infarction?
- Age
- History of injury
- Site/radiation
- Type of pain
- Agg/eas factors
- Associations
What are the investigations for suspected heart attack?
- ECG (first)
- PCI
- CXR
- Biochemical markers
- Oximetry & ABGs
- Echocardiography, CT, MRI, CTPA, V/Q scan
- Exercise test
What are the management options for coronary artery disease?
- CABG
- PCI (percutaneous coronary intervention): Wire inserted into artery, balloon blown up to push blockage aside
