Chest Pain Flashcards
Learn Case 1
What is angina (pectoris)?
Angina is discomfort in the chest and/or adjacent areas (jaw, shoulder, back, arm) caused by myocardial ischaemia. This is most commonly due to coronary artery disease, but there are other causes. It is a SYMPTOM of an underlying heart condition, e.g. atherosclerosis.
Define ischaemia
Inadequate blood supply to an organ/part of the body
Define infarction
Obstruction of blood supply leading to cell death
Name the types of angina
Stable: Typical or Atypical
Unstable
Variant (Prinzmetal’s)
Microvascular
What is stable angina?
This type of chest pain has a pattern. Depending on the type of stable angina, it has 2 or 3 of the following characteristics:
1) Constricting discomfort in the front of the chest, shoulders, neck, jaw or arms.
2) Precipitated by physical exertion
3) Relieved by rest or GTN within about 5 minutes
Typical angina has 3 or these characteristics.
Atypical angina has 2 of these characteristics.
With only 1 of these characteristics, rule out stable angina. It is a form of non-anginal chest pain (msk).
What is unstable angina?
Unstable angina (UA) is an acute coronary syndrome that is defined by the absence of biochemical evidence of myocardial damage. It is characterised by specific clinical findings of prolonged (>20 minutes) angina at rest; new onset of severe angina; angina that is increasing in frequency, longer in duration, or lower in threshold; or angina that occurs after a recent episode of myocardial infarction.
What is microvascular angina?
This is chest pain that is caused by the micro vessels of the heart being blocked. This is unpredictable. It is also known as Cardiac Syndrome X or non-obstructive CAD.
What is variant angina?
Chest pain caused by the spasm of the coronary arteries. About 2/100 angina cases are variant angina - it is rare. Variant angina can occur when the person is at rest.
What are the main risk factors for developing coronary artery disease (CAD)?
Age, gender (men if below 60), smoking, diabetes, hyperlipidaemia, hypertension, obesity.
What important factors of the past medical history are relevant to diagnose CAD?
Con-current diagnosis of CAD (MI history, stable angina), con-current diagnosis of atherosclerotic disease (ischaemic stroke, peripheral vascular disease) and family history of either of the above.
What is the initial management upon diagnosing typical or atypical angina?
Do blood test to identify conditions which exacerbate angina, such as anaemia. Take a resting 12-lead ECG ASAP but do not rule out a diagnosis of stable angina if ECG is normal.
Which changes on a resting 12-lead ECG are consistent with coronary artery disease and may indicate ischaemia/MI?
- pathological Q waves (>40ms, >2mm deep, >25% depth of QRS, seen in V1-3)
- left bundle branch block (broad QRS (>0.12s) and deep S wave in V1 and no Q wave in V5/6)
- ST-segment and T wave abnormalities in leads II & III
What does ST elevation on an ECG indicate?
MI due to artery occlusion = straight into angio.
What does normal ECG with raised Troponin levels indicate?
MI due to partial artery obstruction.
What is the first-line treatment for stable angina?
Beta blocker or a CCB
Also GTN for symptom relief episodes and pre-exercise
At what age is CVD common?
After the age of 60 it is increasingly common. Rare below 30 y/o.
What are the main types of CVD?
Coronary heart disease (CHD), stroke and peripheral arterial disease.
What is CVD due to?
It is generally due to reduced blood flow to the heart, brain or body caused by atheroma or thrombosis.
What is the leading cause of death worldwide, according to WHO?
CVD
How many people who present to A&E with chest pain have MI?
25% have CV issues and only 0.003% of those aren’t MI
What is the main cause of MI?
Coronary artery disease
Aside from CAD, what are causes of myocardial ischaemia?
Aortic stenosis Hypertrophic cardiomyopathy (HOCM) Tachyarrythmias Cocaine use Anaemia Thyrotoxicosis
What is hypertrophic cardiomyopathy?
An autosomal dominant condition characterised by hypertrophy of LV wall.
What is thyrotoxicosis?
A syndrome due to excessive amounts of thyroid hormones in the bloodstream, causing tachycardia, sweating, tremor, loss of weight, heat intolerance (SNS overdrive). Causes are thyroid overactivity and Graves. If caused by Graves, would have goitre and exopthalmos.
What are some non-ischaemic CV causes of chest pain?
Aortic dissection
Pericarditis
(Anaemia)
What are some GI causes of chest pain?
GORD (gastro-oesophageal reflux disease)
Gallstones
Peptic Ulcer
Pancreatitis
What are some Respiratory causes of chest pain?
Pulmonary embolism
Pneumothorax
Pneumonia
Pleurisy
What are some MSK causes of chest pain?
Costochondritis
Herpes Zoster
What is costochondritis?
Also known Tietze’s syndrome. This is a painful swelling of a rib over the junction of bone and cartilage.
What is herpes zoster?
This is known as shingles. It is caused by the varicella-zoster virus which also causes chickenpox. Following an attack of chickenpox, the virus lies dormant in the dorsal ganglia of the spinal cord. It can later be influenced to migrate down the sensory nerve and attack one or more of the dermatomes of the skin, causing the shingles rash. The chest pain can come before the rash.
What are the key things to do when someone presents with chest pain?
History
Examination
ECG
Troponin
How do visceral and somatic pain present?
Visceral pain is poorly localised. Somatic pain is localised and has a specific site.
What does very sudden onset of chest pain make you think?
Pulmonary embolism.
What does a pressure/heavy/tight pain make you think?
Acute coronary syndrome (ACS)
GORD
What does indigestion/belching make you think?
GORD
but ALSO ACS
What kind of thing would you think if the pain were severe, ripping?
Aortic dissection
What should sharp, stabbing pain make you think?
PLEURITIC PAIN
MSK
What do various radiations of chest pain indicate?
L arm or both, jaw and neck = ACS
R shoulder = cholecystitis
Intrascapular, back = aortic dissection, GORD, pancreatitic, peptic ulcer, ACS.
Epigastrum = pancreatitis, peptic ulcer, gallstones, ACS
What do different associated features of chest pain indicate?
Nausea, vomiting = ACS, upper GI
Sweating, clammy = ACS, P.E, aortic dissection
Shortness of breath = ACS, Resp
Hypotension/syncope = P.E, ACS, aortic stenosis
What do the different lengths of time of chest pain indicate?
Seconds = MSK, non-cardia
Minutes = ACS, GORD, MSK
Hours = All
Days, persistent pain = not ACS
What do the different exacerbations of chest pain . indicate?
Exertion/emotion = angina Eating = ACS, GORD, Peptic ulcer Position = percaditis, GORD, MSK, pancreatitis
Which examinations should you think of doing with chest pain presentation?
CV, Resp, Abdo
Which questions can you ask to rule out abdo/resp/neuro causes of chest pain?
If any: vomiting coughing haematopsis short of breath dizziness funny taste at back of mouth (acid)