Chest Pain

Question 1

What are the three features of angina?

Answer 1

1. Constricting/heavy discomfort to the chest, jaw, neck, shoulders or arms
2. Symptoms brought on by exertion
3. Symptoms relieved by rest

Question 2

How is angina classed?

Answer 2

3 features = typical
2 feature = atypical
0-1 features = non-anginal chest pain

Precipitate by lying flat = decubitus angina
Due to coronary artery spasm = vasospastic angina

Question 3

What else can precipitate angina?

Answer 3

emotion
cold weather
heavy meals
lying flat - decubitus angina

Question 4

What are some associated symptoms with angina?

Answer 4

dyspnoea
nausea
sweatiness
faintness

Question 5

Which features might make angina less likely?

Answer 5

pain that is continuous, pleuritic, worse with swallowing food or associated with palpitation, dizziness or tingling

Question 6

What are the causes of angina?

Answer 6

atheroma

Rare: anaemia, coronary artery spasm, AS, tachyarrhythmias, HCM, arteritis

Question 7

What tests do you do if you suspect angina?

Answer 7

Blood tests: 
FBC - pneumonia? anaemia?
Troponin - MI?
Lipids - hyperlipidaemia?
HBA1c - diabetes?
TFTs - thyrotoxicosis?
Us & Es - low Mg?

ECG
CXR
CT angiography
Exercise ECG
Upper GI endoscopy

Question 8

What are some exacerbating factors of angina?

Answer 8

anaemia
tachycardia
thyrotoxicosis

Question 9

How do you manage angina?

Answer 9

PRN symptom relief
Address exacerbating factors
2* prevention of CVD
Anti-anginal medication
Revascularisation

Question 10

What exacerbating factors do you address with angina?

Answer 10

Anaemia
Tachycardia
Thyrotoxicosis

Question 11

What is the 2* prevention of CVD?

Answer 11

Stop smoking
Exercise
Dietary advice
HTN management
Diabetes control
75mg aspirin daily if not contraindicated
Hyperlipidaemia management
Consider ACE inhibitors

Question 12

What is the PRN symptom relief of angina?

Answer 12

GTN spray or sublingual tabs.
Advise patient to repeat the dose if pain hasn’t gone in 5 mins, and to call an ambulance if still present after the second dose
SE: headaches,

Question 13

What anti-anginal medication do you give?

Answer 13

First line: beta-blocker &/or CCB.
Bisoprolol 5-10mg OD
Atenolol 50mg OD
Amlodipine 5mg OD

Then trial:
Long-acting nitrate: isosorbide mononitrate
Nicorandil: 5-10mg BD Contra if acute PO,

Question 14

What are the options for revascularization?

Answer 14

PCI: open lumen with balloon and may use stent. Dual antiplatelet therapy is recommended for 12 months after stent insertion.

CABG: better with multivessel disease but higher risk as open surgery so recovery is slower and two large wounds.

Question 15

How do you manage an acute STEMI that walks through the door?

Answer 15

“MONA”
Morphine, O2, Nitrates, Aspirin

ECG
IV access for: FBC, Us&Es, Troponin, Glucose, HBA1c, lipids
Brief assessment
CXR
Aspirin 300mg
Ticagrelor 180mg
Morphine 5-10g + anti-emetic (metoclopramide 10mg IV)
GTN
O2 if <95%
If PCI is available within 2 hours head straight to that, if not, fibrinolysis then head to PCI.