Chest pain Flashcards
The commonest causes of CP encountered in general
practice are ___ and ____
musculoskeletal or chest wall pain
and psychogenic disorders
Other terms for MSK pain
fibrositis or neuralgia
If angina-like pain lasts longer than
15 minutes _____ must be excluded
myocardial infarction
Red flag pointers for acute chest pain
- Dizziness/syncope
- Pain in arms L>R, jaw
- Thoracic back pain
- Sweating
- Palpitations
- Dyspnoea
- Pain or inspiration
- Pallor
- Past history: ischaemia, diabetes, hypertension
Dx of CP
Pitfalls
referred pain from spinal disorders, especially of
the _______—one of the great pitfalls
in medical practice
lower cervical spine
Dx of CP
Pitfalls
being unaware that up to __________are silent, especially in elderly patients,
and that pulmonary embolism is often painless
20% of myocardial
infarctions
Pathological fractures
secondary to osteoporosis or malignancy in the
vertebrae cause _______
posterior wall pain
With _______ causes the pain can occur anywhere
in the chest, and tends to be continuous and sharp
or stabbing rather than constricting
psychogenic
Associated symptoms
_______ Consider myocardial infarction,
pulmonary embolus and dissecting aneurysm
• Syncope.
Associated symptoms
_________. Consider pleuritis,
pericarditis, pneumothorax and musculoskeletal
(chest wall pain).
Pain on inspiration
Associated symptoms
_________. Consider spinal dysfunction,
acute coronary syndromes, angina, aortic
dissection, pericarditis and gastrointestinal
disorders such as a peptic ulcer, biliary colic/
cholecystitis and oesophageal spasm
Thoracic back pain
auscultation of chest:
— reduced breath sounds, hyper-resonant percussion note and vocal fremitus → \_\_\_\_\_\_\_\_\_\_ — friction rub → \_\_\_\_\_\_\_\_\_\_ — basal crackles →\_\_\_\_\_\_\_\_
pneumothorax
pericarditis or pleurisy
cardiac failure
auscultation of chest:
— apical systole murmur →_____
— aortic diastolic murmur → _____
mitral valve prolapse
With an ______ the patient may
also appear cold, clammy and shocked, but may show
absent femoral pulses, hemiparesis and a diastolic
murmur of aortic regurgitation
aortic dissection
The ECG in _______ may be
normal but if massive may show right axis deviation,
right BBB and right ventricular strain
pulmonary embolism
________ is
characterised by low voltages and saddle-shaped ST
segment elevation.
Pericarditis
Physical stress, such as the motor-driven
treadmill or a bicycle ergometer, is used to elicit
changes in the ECG to diagnose myocardial ischaemia
Exercise stress test
This radionuclide myocardial perfusion scan using
thallium can complement the exercise ECG
Exercise thallium scan
This monitor is especially useful for silent ischaemia,
variant angina and arrhythmias
Ambulatory Holter monitor
Isotope scanning
1 _____________
• myocardium—to diagnose posterolateral
myocardial infarction in the presence of bundle
branch block
• pulmonary—to diagnose pulmonary embolism
Technetium-99m pyrophosphate studies:
Isotope scanning
__________—this scan tests left
ventricular function at rest and exercise in
patients with myocardial ischaemia
Gated blood pool nuclear scan (radionucleide
ventriculography)
This investigation is for dissecting aneurysm
immediate diagnosis
Transoesophageal echocardiography (TOE)
______
or pain situated across the chest anteriorly should be
regarded as cardiac until proved otherwise
Retrosternal pain
Pain is referred into the left arm _____
more commonly than into the right arm.
20 times
Stable angina.
The pain of angina tends to last a few
minutes only (average 3–5 minutes) and is relieved by
_________ The pain
may be precipitated by an_____
rest and glyceryl trinitrate (nitroglycerine).
arrhythmia
___________
Ischaemic pain lasting
longer than 15 to 20 minutes is usually
infarction. The pain is typically heavy and
crushing, and can vary from mild to intense.
Occasionally the attack is painless, typically in
diabetics. Pallor, sweating and vomiting may
accompany the attack
Myocardial infarction.
Unstable angina.
This term includes rest angina,
new onset effort angina, post infarct angina
and post coronary procedure angina. Severe
ischaemic chest pain can last 15–20 minutes
or more. It is classified as low risk or high risk
‘minor myocardial damage
Unstable angina.
For management purposes it is best to classify the
clinical presentation of acute ischaemic chest pain as
an ___ or ______
ST elevation myocardial infarction (STEMI) or a
non-ST elevation acute coronary syndrome (NSTEACS),
which includes NSTEMI and unstable angina.
The pain, which is usually sudden, severe and
midline, has a tearing sensation and is usually
situated retrosternally and between the scapulae
Aortic dissection
An important diagnostic feature of aortic dissectionis the
inequality in the pulses (e.g. carotid, radial and femoral
This has a dramatic onset following occlusion of
the pulmonary artery or a major branch, especially
if more than 50% of the cross-sectional area of the
pulmonary trunk is occluded.
PE
The diagnosis of PE is usually confirmed
by a
- ______ (best) and/or
- V/Q scan (see later in chapter) and
ECG (look for _____
CT pulmonary angiogram
T wave inversion V1–V4).
Inflammation of the pleura is due to underlying
pneumonia (viral or bacterial), pulmonary infarction,
tumour infiltration or connective tissue disease (e.g.
Pleuritis
Unilateral knife-like chest pain (and upper abdominal
pain) following an URTI. It is caused by a Coxsackie
B viru
Epidemic pleurodynia (Bornholm disease)
Pericarditis causes three distinct types of pain:
1 __________ aggravated by cough
and deep inspiration, sometimes brought on by
swallowing; worse with lying flat, relieved by
sitting up
2 ___________ that mimics
myocardial infarction
3 pain synchronous with the heartbeat and felt
over the praecordium and left shoulder
pleuritic (the commonest),
steady, crushing, retrosternal pain
The cardinal sign of acute pericarditis is
a pericardial friction rub.
The acute onset of pleuritic pain and dyspnoea in a
patient with a history of asthma or emphysema is the
hallmark of a _______
pneumothorax
Causes of PTX
It is due to a rupture of
a subpleural ‘bleb’ or a small air-containing cyst
________ can cause oesophagitis
characterised by a burning epigastric or retrosternal
pain that may radiate to the jaw
Gastro-oesophageal reflux
What worsens GERD
after meals, and is more frequent at night. The pain
is worse if oesophageal spasm is present
The commonest cause of pain of spinal origin is
vertebral dysfunction of the ____
lower cervical or upper
dorsal region
This causes mild to moderate anterior chest wall pain
that may radiate to the chest, back or abdomen. It is
usually unilateral, sharp in nature and exaggerated
by breathing, physical activity or a specific position
Costochondritis
there is a tender, fusiform swelling
at the costochondral junction
Tietze
syndrome
can occur anywhere in the
chest, but often it is located in the left submammary
region, usually without radiation
Psychogenic chest pain
______ is recurrent
attacks of stabbing left-sided submammary pain,
usually associated with anxiety ± depression
Da Costa syndrome (effort syndrome)
Chest pain in children younger than 12 years
old is more likely to have a ______
cardiorespiratory cause,
such as cough, asthma, pneumonia or heart disease
chest pain in adolescents is more likely to be
associated with a _____
psychogenic disturbance
This complaint, which is common in children and
adolescents, presents as a unilateral low chest pain
that lasts usually 30 seconds to 3 minutes, typically
with exercise, such as long-distance running
Precordial catch (Texidor twinge or stitch in the side
The elderly patient presenting with chest pain is
most likely to have_____
angina or myocardial infarction
•an oppressive discomfort rather than a
pain.
• It is mainly retrosternal: radiates to arms, jaw,
throat, back.
• It may be associated with shortness of breath,
nausea, faintness and sweating
Angina pectoris
Ddx for angina pectoris
Mitral valve prolapse, oesophageal spasm and
dissecting aneurysm are important differential
diagnoses
(also referred to as crescendo
angina, pre-infarct angina and acute coronary
insufficiency).
Unstable angina
______Pain occurs during the
night. It is related to unstable angina
Nocturnal angina.
______ The pain occurs when lying
flat and is relieved by sitting up.
Decubitus angina.
The pain occurs at rest and without
apparent cause.
It is
caused by coronary artery spasm.
Variant angina or Prinzmetal angina or spasm
angina
ECG of Variant angina or Prinzmetal angina or spasm
angina
It is associated with typical
transient ECG changes of ST elevation (as
compared with the classic changes of ST
depression during effort angina).
T or F
A normal stress test does not
rule out coronary artery disease
T
It helps determine the presence
and extent of reversible myocardial ischaemia since
thallium is only taken up by perfused tissue.
Exercise thallium-201 scan
This test assesses the ejection fraction, which is a reliable
index of ventricular function and thus aids assessment
of patients for coronary artery bypass surgery
Gated blood pool nuclear scan
This test accurately outlines the extent and severity of
coronary artery disease. It is usually used to determine
the precise coronary artery anatomy prior to surgery
Coronary angiography
Indications for coronary angiography 1 2 3 4
Strong positive exercise stress test
Suspected left main coronary artery disease
Angina resistant to medical treatment
Suspected but not otherwise proven angina
Indications for coronary angiography
5
6
7
Angina after myocardial infarction
Patients over 30 years with aortic and mitral valve
disease being considered for valve surgery
General advice for the stable angina
patient
• Reassure patient that angina has a reasonably
good prognosis: 30% survive more than
10 years; 8 spontaneous remission can occur
What tog give during acute angina
ISDN
Forms of nitrates
glyceryl trinitrate (nitroglycerine) 600 mcg tab
or
300 mcg (½ tab) sublingually (SL)
or
glyceryl trinitrate SL 400 mcg metered dose
spray: 1–2 sprays; repeat after 5 minutes if pain
persists (maximum two doses)
or
isosorbide dinitrate 5 mg sublingually; repeat
every 5 minutes if pain persists (maximum 3
tablets)
Can CCB be given during acute angina?
nifedipine 5 mg capsule (suck or chew) if
intolerant of nitrates
How to give nitrate tabs
- take ½ (initially) or 1 tablet every 5 minutes
* take a maximum of 3 tablets in 15 minutes
avoid _______ if patient has taken sildenafil
or vardenafil in the previous 24 hours or tadalafil in
the previous 5 days
nitrates
Mild stable angina Tx
(Angina that is predictable, precipitated by more
stressful activities and relieved rapidly)
• aspirin 150 mg (o) daily
or
(if intolerant of aspirin) clopidogrel 75 mg (o)
daily glyceryl trinitrate (SL or spray) prn
• Consider a beta blocker or long-acting nitrate or
nicorandil
Moderate stable angina
(Regular predictable attacks precipitated by moderate
exertion)
What meds to add on top of meds for stable
beta blocker e.g. atenolol 25–100 mg (o) once daily
or
metoprolol 25–100 mg (o) twice daily
plus nitrates
glyceryl trinitrate (transdermal: ointment or
patches) daily (use for 12–16 hours only)
or
isosorbide mononitrate 60 mg (o) SR tablet mane
Aim for Moderate stable angina
Moderate stable angina
Define persistent angina
Not prevented by beta blocker
Mx of Persistent angina
add a dihydropyridine calcium-channel blocker (CCB)
(must have beta blocker cover)
nifedipine CR 30–60 mg (o) once daily
or
amlodipine 2.5–10 mg (o) once daily
plus nitrates
Mx of Persistent angina
If beta blocker contraindicated
(use a nondihydropyridine
calcium-channel blocker):
diltiazem 30–90 mg (o) tds or CR 180–360 mg (o) daily or verapamil (according to directions) and/or nicorandil 5 mg (o) bd, increasing after a week to 10–20 mg bd plus nitrates
Refractory stable angina MX
Replace CCB with perhexiline
Includes onset of angina at rest, abrupt worsening
of angina and angina following acute myocardial
infarction
Unstable angina
For variant angina (spasm) use nitrates and calcium antagonist (avoid\_\_\_\_\_\_
beta blockers).
As a rule, avoid the combination of verapamil and a beta blocker (risk of \_\_\_\_\_\_
tachycardia and heart block).
T or F
Tolerance to nitrate use is a problem, so 24-hour
coverage with long-acting preparations is not
recommended.
______can be used prophylactically prior to
any exertion that is likely to provoke angina
Nitrates
One current technique for CAD is dilating coronary
atheromatous obstructions by inflating a balloon
against the obstruction—___________
percutaneous transluminal coronary angioplasty (PTCA)
Two complications of the balloon inflation
angioplasty are _____ and ______which occurs in 30% in the first 6 months after angioplasty
acute coronary occlusion (2–4%) and
restenosis,
_______is now the most favoured
procedure to maintain patency of the obstructed
coronary vessel
PTCA followed by stenting
_______, which include drugs such as primolimus,
sirolimus or paclitaxel, can be used as well as the
bare metal stent.
Modern drug eluting
stents
Veins used in CABG
saphenous
internal mammary
Symptomatic patients with significant __________ should undergo bypass surgery,
and those with two or three vessel obstruction and
good ventricular function are often considered for
angioplasty or surgery
left main
coronary obstruction
Silent infarcts may occur in?
‘Silent infarcts’ in diabetics, hypertensives,
females and elderly;
Dx of MI
Diagnosis is based on 2 out of 3 criteria: history
of prolonged ischaemic pain, typical ECG appearance,
and rise and fall of cardiac enzymes
Etiology of MI 1 2 3 4
- Thrombosis with occlusion
- Haemorrhage under a plaque
- Rupture of a plaque
- Coronary artery spasm
Impt signs in MI
• variable pulse: watch for _______
• mild ______: third or fourth heart sound,
basal crackles
bradyarrhythmias
cardiac failure
ECG of MI is suggestive of?
full thickness infarction
Characteristics of Q wave
broad (>1 mm) and deep >25% length R wave
— occurs normally in leads AVR and V1; III
sometimes
— abnormal if in other leads
Q wave can also occur in
LBBB, WPW and ventricular tachycardia (VT)
Q waves do not develop in ____
subendocardial
infarction.
The strategies for management of AMI are based
on the _____
distinction between Q wave (transmural)
or non-Q wave (subendocardial) infarction
Q wave infarction has been proved to benefit
from ______ but non-Q wave
infarction has not
thrombolytic therapy
T or F
A normal ECG, especially early, does not exclude
AMI.
T
Q waves may take days to develop
What enzyme?
— starts rising at 3–6 hours, peaks at 10 hours
and persists for about 5–14 days
— now the preferred test
— positive in unstable angina
Troponin I or T:
T or F,
Trop I or Trop T is useful in repeat MI
F
What enzyme?
— after delay of 6–8 hours from the onset of
pain it peaks at 20–24 hours and usually
returns to normal by 48 hours
creatinine kinase (CK):
______: myocardial necrosis is present
if >15% of total CK; unlike CK, it is not
affected by intramuscular injections
CK–MB
• It is performed from 24 hours to 14 days after
onset.
• It scans for ‘hot spots’, especially when a
posterolateral AMI is suspected and ECG is
unhelpful because of pre-existing LBBB.
Technetium pyrophosphate scanning
Management of acute coronary syndromes
Prevent and treat cardiac arrest; have a ____
available to treat ventricular fibrillation
defibrillator
Management of acute coronary syndromes
• Give _____ as early as possible (if no
contraindications).
• Prescribe a_______
early (if no contraindications
aspirin
beta blocker and an ACE inhibitor
For a STEMI it is important to re-establish
flow as soon as possible, usually by either____ or _____
thrombolytic
therapy or primary angioplasty (preferably with
stenting).
The optimal first-line treatment for the patient with a
STEMI is ______
ideally within 60 minutes (the golden hour) of the onset
of pain
urgent referral to a coronary catheter laboratory (PTCA)
Adjunct therapy for STEMI will include:
aspirin/clopidogrel
and heparin and possibly a glycoprotein IIb/IIIa platelet
inhibitor such as prasugrel, ticagrelor or abciximab
Management of NSTEACS
If angioplasty is unachievable either through timing
or the unavailability of the service (such as in rural
locations) ______is an indication for STEMI
thrombolysis
Golden period for thrombolysis in STEACS
within
12 hours of the commencement of chest pain.
What is the ideal fibrinolytic
Second-generation fibrin-specific agents (reteplase,
alteplase or tenecteplase) are the agents of choice
Fibrinolytic for NSTEACs
____ can be used but it is inappropriate for
use in Indigenous people and those who have received
it on a previous occasion
Streptokinase
Further management for NSTEACs
Full heparinisation for 24–36 hours (after
rt-PA—not after streptokinase), especially for
__________, supplemented by warfarin
large anterior transmural infarction with risk of
embolisation
Further management for NSTEACs
\_\_\_\_\_\_\_\_(if no thrombolytic therapy or contraindications) as soon as possible: atenolol 25–100 mg (o) daily or metoprolol 25–100 mg (o) twice daily
Beta blocker
Further management for NSTEACs
Start early introduction of ACE inhibitors
(within 24–48 hours) in those with significant
_________ (and other
indications).
left ventricular (LV) dysfunction
Further management for NSTEACs
• Statin therapy to lower cholesterol. • Treat \_\_\_\_\_\_\_\_. • Consider \_\_\_\_\_\_\_\_\_ (after thrombolysis). • Consider frusemide.
hypokalaemia
magnesium sulphate
Special management issues
Indications for coronary angiography
- Development of angina
- Strongly positive _______test
- Consider after use of_____
exercise
streptokinase
basal crackles, extra (third or fourth) heart
sounds, X-ray changes
Acute left ventricular failure
Cardiogenic shock (a major hospital management procedure)
Requires early specialist intervention which may include 1 2 3
- treat hypotension with inotropes
- intra-aortic balloon pump
- urgent angiography ± angioplasty/surgery
This occurs in first few days after AMI (usually
anterior AMI), with onset of sharp pain.
What Cx STEMI?
Pericarditis
SIgns of Pericarditis
pericardial friction rub
Tx of Pericarditis
anti-inflammatory medication (e.g.
aspirin, indomethacin or ibuprofen for pain) with
caution
What to avoid in pericarditis?
anticoagulant
This occurs weeks or months later, usually around
6 weeks.
• Features: pericarditis, fever, pericardial effusion
(an autoimmune response)
Post-AMI syndrome (Dressler syndrome
What Cx STEMI?
- Clinical: cardiac failure
- Features: arrhythmias, embolisation
• Signs: double ventricular impulse, fourth heart
sound, visible bulge on X-ray
Left ventricular aneurysm
Left ventricular aneurysm Mx 1 2 3 4
— antiarrhythmic drugs
— anticoagulants
— medication for cardiac failure
— possible aneurysmectomy
This presents with severe cardiac failure and a loud
pansystolic murmur. Both have a poor prognosis and
early surgical intervention may be appropriate
Ventricular septal rupture and mitral valve
papillary rupture
Aortic dissection
• Early definitive diagnosis is necessary: best
achieved by ________
transoesophageal echocardiography
Aortic dissection
Emergency surgery needed for many, especially
for ________
type A (ascending aorta involved).
Tx of PE
heparin IV: 5000 U as immediate bolus,
continuous infusion 30 000 U over 24 hours
or
heparin 12 500 U (sc) bd
PE
The dose of heparin should then be adjusted
daily to maintain the APTT between ____
1.5 and 2 times
control.
Heparinization sched for PE
Continue heparin 5–10 days
Drainage of the pleural space indicated for a
large pneumothorax _______ pleural area, with
persistent dyspnoea
> 25%
PTx Tx
— <25% collapse, no symptoms: ___
— <25% collapse + persisting symptoms: _____
— >25% collapse: usually drain
observe
drain
PTx Tx
For recurrent attacks, excision of____ or ____
cysts or
pleurodesis may be necessary
Statistics indicate a 30–50% recurrence rate
of spontaneous pneumothorax (most within
12 months), _____ on the same side, _____
on the opposite side
35%
10–15%
Acute tension pneumothorax Tx
For urgent cases insert a 12–16 gauge needle into
the pleural space through the ______
second intercostal
space on the affected side.
Mx of Esophageal Spasm
Long-acting nitrates (e.g. isosorbide dinitrate
10 mg tds)
or
Calcium-channel blockers (e.g. nifedipine CR
20–30 mg once daily)
Costochondritis is a common cause of anterior
pain, which is generally well localised to the
costochondral junction and may also be a component
of an inflammatory disorder, such as one of the
_________
spondyloarthropathies
______ is often an undiagnosed
cause of chest pain: keep it in mind, especially
if pain is recurrent and intermittent (proved by
echocardiography).
Mitral valve prolapse
______ can cause peripheral oedema,
so be careful not to attribute this to heart failure
Calcium antagonists
The pain of______ can be very
severe and mimic myocardial infarction.
oesophageal spasm
Oesophageal spasm responds to _____
do not confuse with angina
glyceryl trinitrate:
______ are a very rare
cause of severe sudden thoracic pain (T2–9).
Intervertebral disc protrusions
Infective endocarditis can cause _____
pleuritic posterior
chest pain
The sudden onset of dyspnoea without chest pain
can occur frequently with ____ and ____
(painless) myocardial
infarction and pulmonary embolism
