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)
Does a normal ECG exclude ACS if a person presents with chest pain?
NO
What is ACS?
Acute coronary syndrome consisting of unstable angina, STEMI and NSTEMI
Which is more common, NSTEMI or STEMI?
NSTEMI
If someone has ACS, what other factors put their prognosis at risk?
Age, diabetes, renal failure, co-morbidities, tacky/hypo
What are risk scores in ACS?
Ischaemic risk - GRACE
Bleeding risk - CRUSADE
Which revascularisation surgeries are there?
PCI, CABG
What are the 5 key management steps of ACS?
- Clinical evaluation
- Diagnosis and risk assessment
- Drug therapy and invasive strategy
- Revascularisation decision
- Discharge and long term management
What is the long term management of ACS?
- Aspirin for life and antiplatelet therapy (clopidogrel)
- Statins
- Beta blockers if LVEF <40
- ACE inhibs/ARB/Aldosterone antags if LVEF <40
Why are patients kept in a coronary care unit after an MI?
So their hearts can be monitored 24hours a day to check for common complications after an MI.
What are common complications of the heart after an MI?
V Fib
V Tach
What is V Fib?
When the electrical current of the v is in a jumble and the v is just spasming. Loss of coordinated contraction - just random firing of the muscle cells.
LIFE THREATENING - unconscious with no pulse. Signs of an MI w/ chest pain, cyanosis.
What are the risk factors of V Fib?
Irritable Ventricular Cells - CAD, electrolyte abnormalities
Scar Tissues - MI, cardio myopathy, CAD
Electrocution
What is V Tach?
Rapid heart beat of the ventricles - up to 250bpm. This heartbeat is too fast for the diastole to be sufficient, and so the blood circulation is decreased. Wide QRS.
There are two types - focal and reentrant (scar).
EMERGENCY
What are the symptoms of V Tach?
Shortness of breath Chest pain Palpating Lightheaded Dizzy Faint
What are the risk factors of V Tach?
Irritable Cells (focal) - CAD, electrolyte abnormalities Scar tissue (reentrant) - MI, cardio myopathy
What is SVT?
Supraventricular tachycardia (atrial tachycardia) HR = >100bpm at rest.
What are the symptoms of SVT?
DIzziness, chest pain, anxiety, palpitation, shortness of breath
What are the risk factors of SVT?
Inherited mutations Structural abnormalities CAD COPD PE Heart Failure Alcohol Hyperthyroidism
What do you see on an ECG with A Fib?
No distinct p waves, irregularly irregular beat
What are the risk factors for AF?
Diseased atrial tissue - age, inflammation, enlarged atria
Hormonal abnormalities
Alcohol abuse
What meds do people with AF need and why?
Blood thinner - clopidogrel/ticagrelor
Due to pooling of blood to create clots and higher risk of stroke
Which valves close on S1/S2?
S1 = M & T S2 = A & P
Which are the systolic murmurs?
These occur after S1, and are: Aortic stenosis Pulmonary stenosis Mitral regurgitation/mitral valve prolapse Tricuspid regurgitation
Which are the diastolic murmurs?
These occur after S2, and are: Aortic regurgitation Pulmonary regurgitation Mitral stenosis Tricuspid stenosis
Describe what you hear in aortic stenosis.
You will hear S1, then a tiny gap, then a click followed by a crescendo/decrescendo murmur. Also known as a diamond shape murmur.
SYSTOLIC EJECTION MURMUR, HEARD MOST LOUDLY AT AORTIC AREA.
Can radiate to the neck as the carotids are some of the closest arteries to the aortic.
Describe what you hear in pulmonic stenosis
Systolic ejection murmur, with a systolic click and crescendo/decrescendo.
Heard in pulmonic area.
Describe what you hear in mitral regurgitation.
Heard best in mitral area.
PAN-SYSTOLIC MURMUR - heard at the same level of sound (flat murmur) through the whole of systole S1-S2
Mitral valve never fully closes so when ventricles go to contract, at S1, blood pushes back through mitral valve into the L atrium (dilated).
Radiates to the axilla.
Describe what you would hear in tricuspid regurgitation.
The same as mitral regurgitation.
Pan-systolic, flat murmur heard in tricuspid area.
Doesn’t radiate to axilla.
What is the first line analgesic prescribed in a STEMI?
Morphine, along side an antiemetic and titrated to response. Morphine has both anxiolytic and analgesic effects.
Nitrates are also used.
What do you give ASAP in suspected ACS?
Aspirin 300mg P.O. to be chewed or sucked
Pain - GTN or IV Morphine 2-4mg if necessary
What is the immediate treatment of ACS?
Aspirin
Antithrombin therapy if no planned PCI.
Consider ticagrelor
What does it mean when somebody says ‘definitive treatment’?
The treatment that will reverse the problem.
What should you listen for after MI?
Murmurs! Has the MI damaged the heart?
E.g. valve leaflet
What does severe pain that radiates to the back, mid scapular indicate?
Aortic dissection
Why do some people still use thrombolysis?
If they are too far away from PCI facilities, e.g.parts of Scotland, third world countries
What are the major complications of MIs?
Decreased contractility:
–> reduced CO = hypotension =
How does VSD lead to pulmonary damage?
Left side of heart is higher pressured and if this leaks into right side then goes into the pulmonary vessels
How do the papillary muscles and chordae tendonae relate?
Papillary muscles are in the heart wall and the chordae tendonae are string like and attach to the valve flaps. Papillary muscles necrose in MIs
What is the drug treatment for secondary prevention of ACS?
ACE inhibitors Dual antiplatelet therapy Anti-coagulants Beta-blocker Statin
What is dual antiplatelet therapy?
Aspirin and second anti platelet e.g. clopidogrel
What do troponins reflect the amount of?
Myocardial cellular damage
When do troponins rise and for how long can they be elevated?
2-4 hours post MI
Elevated for 2 week
What is the drug treatment for secondary prevention of stable angina?
Low dose aspirin 75mg daily
What drug treatment should be given if someone has stable angina and diabetes mellitus?
ACE inhibitor
Sum up the drug treatment of diagnosed stable angina.
Initial treatment after diagnosis is symptom relief with GTN.
Either beta blocker or CCB as first-line treatment for angina.
Then consider 75mg aspirin daily as secondary prevention, considering ACE inhibitors for those with diabetes mellitus.
What is the initial management of stable angina (drugs and investigations pre-diagnosis)?
Consider 300mg aspirin and GTN for pain relief.
ECG
64+ slice CT angiography for diagnosis.
If unsure:
MPS with SPECT
Stress echo
What do you consider if stable angina doesn’t respond to treatment?
Consider CABG and PCI
What is the diagnostic test for stable angina?
64-slice (or more) CT angiography
When do we offer O2 for those with chest pain?
If sats less than 94% and no risk of hypercapnia - aim 94-98%
If COPD and at risk of hypercapnia - aim 88-92%
What is the universal definition of myocardial infarction in relation to diagnosing?
Rise/fall of troponin with one of:
STEMI: New LBBB
>/= 1mm STE in leads II and III
Symptoms of ischaemia New ST-T changes Pathological Q waves Imaging of loss of myocardium Thrombus found PCI
What is the managing treatment of a STEMI?
Reperfusion therapy - PCI.
If PCI cannot be delivered within 90 mins, offer fibrinolysis - ALTEPLASE 15mg then IV depends on weight.
What four acute conditions should you be thinking upon chest pain?
ACS
Acute pulmonary oedema
Tension pneumothorax
PE
Summarise the treatment of ACS
All - give aspirin 300mg and GTN/morphine for pain relief, think about O2 if hypoxic. Give clopidogral/ticagrelor
UA/NSTEMI: Heparin/LMWH/fondeparinux Na BB ACEi Tirofiban in high MI/death risk patients
STEMI: PCI w/ heparin within 90 mins OR Alteplase Heparin/LMWH/fondeparinux Na BB ACEi
Eplenerone if LVEF<40%
Long-term: Aspirin (at least 12months) Rivaroxiaban Clopiogrel Statin ACEi BB (bisoprolol) CCB (amlodipine)
When would one consider CABG over PCI?
Multi-vessel disease
What is this murmur?
Early diastolic murmur heard best at the left 4th intercostal space with the patient sat forward in expiration
Aortic regurgitation
What is this murmur?
Pansystolic murmur heard loudest at the apex of the heart radiating to axilla.
Mitral regurgitation
What is this murmur?
Mid-diastolic rumbling murmur, heard best with the bell of the stethoscope at the apex with the patient in the left lateral position
Mitral stenosis
What is this murmur?
Ejection systolic murmur heard loudest in the aortic area radiating to the carotids.
Aortic stenosis
Do you manage ACS patients with psychological interventions such as CBT?
No.
Cardiac rehab programme
What sort of diet is good to advise patients with ACS?
Oily fish
High fibre
High fruit and veg
Low saturated fats (fatty beef, cheese, lamb, pork)
Which team members are there in cardiac rehab programmes?
Doctor Nurse Physio Exercise Occupational health Dietitian Psychologist
What advice can you give patients re driving?
Group 1 can drive 1wk after angioplasty and 4wks after ACS without angioplasty (if LVEF >40%)
Group 2 must inform DVLA about ACS and stop driving for at least 6wks and subject to functional tests
What time of day do you take statins? and why?
At night because the liver breaks down cholesterol at night
What advice can you give about returning to work?
Most people can return to work but should speak to supervisor about modifying duties for a while.
Airline pilots and traffic control may not be able to restart.
Public services and heavy machinery have to wait for functional tests.
Which imbalances in the body increase risk of tachyarrhythmias?
Hypokalaemia
Hypoxia
Acidosis
