Chest Pain

Question 1

Spectrum of conditions making up Acute Coronary Syndrome

Answer 1

Stable angina - exertion –> chest pain, relieved with rest/GTN

Unstable angina –> chest pain, even at rest

NSTEMI - coronary artery occlusion –> ischaemia + distal infarct

STEMI - coronary artery occlusion –> transmural infarct

Question 2

Initial investigations in ACS?

Answer 2

12 lead ECG - confirm cardiac aetiology
(normal ECG doesnt rule out transient ST elevation)

Cardiac enzymes - 3-6 hours after onset of chest pain
Baseline bloods - FBC, U&E, glucose, lipid profile

Question 3

Acute management of ACS?

Answer 3

MOAN

Morphine - 2-4mg, IV (+ antiemetic)
Oxygen - high flow, if sats <94% (ONLY if needed)
Aspirin - 300mg Loading dose, + 75mg OD.
+ Ticagrelor (180mg)/clopidogrel (300mg)
Nitrates (GTN) - 0.3-1mg sublingual

Question 4

Definitive management of a STEMI

Answer 4

MOAN for acute

Straight for PCI/CABG
+ anticoagulation (LMWH)
+ beta blocker if haemodynamically stable

Question 5

Differential diagnosis for ACS?

Answer 5

Pericarditis
AAA
PE
pericardial effusion/tamponade
Anxiety attack
oesophageal spasm/rupture

Question 6

What are the classification of aortic dissection

Answer 6

Type A - I = ascending + descending
II = ascending only
Type B = descending only

Mortality higher for type A

Question 7

Management of aortic dissection

Answer 7

Type A - straight to surgery

Type B - try to stabilise - lower BP with labetalol IV/CCB
+ IV morphine (+antiemetic)