Chest Pain Flashcards
What percentage of chest pain cases are from cardiovascular causes?
25%
What percentage of cases of chest pain are from non-cardiovascular causes?
75%
Name the 2 main causes of cardiovascular chest pain and 2 examples of each cause
- Myocardial Ischemia (most common) -> coronary artery disease (commonest cause in UK), aortic stenosis
- Cardiovascular non-Ischemia (0.003% of A&E cases) -> aortic dissection, pericarditis
Name 6 other causes of myocardial ischemia other than CAD
- Aortic stenosis
- Hypertrophic cardiomyopathy
- Tachyarrhythmias
- Cocaine use
- Anemia
- Thyrotoxicosis
Name 3 main causes of non-CVS chest pain and examples of each
- Upper GI
- GORD
- Gallstones
- Peptic ulcer
- Pancreatitis - Respiratory
- Pneumonia
- Pneumothorax
- PE
- Pleurisy - Musculoskeletal
- Costochondritis
- Herpes Zoster
When taking a history from the patient, use SOCRATES to understand their pain.
SITE:
What would diffuse/poorly localised pain pain indicate?
Visceral pain (internal organs)
What would localised pain indicate?
Somatic pain (musculoskeletal)
What would sudden onset of pain suggest?
PE
What character of pain is present in ACS/GORD?
- Pressure/heavy/tight
2. Indigestion/belching
What character suggests aortic dissection?
Severe ripping
What character suggests pleuritic pain/musculoskeletal problem?
Sharp, stabbing pain
Where does the pain radiate in ACS?
L arm, both arms, jaw, neck
Where does the pain radiate in cholecystitis?
R shoulder
In what conditions does the pain radiate to the back/intrascapular?
Aortic dissection GORD Peptic ulcer Pancreatitis ACS
In what conditions does the pain radiate to the epigastrium?
Pancreatitis
Peptic ulcer
Gallstones
ACS
What associated features present with ACS?
- Nausea/vomiting
- Sweating
- Shortness of breath
- Hypotension/syncope
What associated features present with PE?
- Sweating
- SOB
- Hypotension/syncope
What associated features present with GI pathology?
Nausea/vomiting
What associated features present with aortic dissection?
Sweating
What associated features present with aortic stenosis?
Hypotension/syncope
Name conditions where the onset of pain is within seconds?
Musculoskeletal
Non-cardiac
Name conditions where onset of pain is within minutes?
ACS
GORD
Musculoskeletal
Name conditions where onset of pain is within hours?
All conditions (non-discriminative time frame)
Name conditions where onset of pain is within days?
Not ACS (dull/persistent pain)
Name a condition where the pain gets worse on exertion/emotion?
Angina
Name conditions where the pain gets worse when eating?
ACS
GORD
Peptic ulcer
Name conditions where the pain gets worse based on position?
Pericarditis
GORD
Musculoskeletal
Pancreatitis
What 3 physical examinations should you perform on a patient complaining of chest pain?
- Cardiovascular
- Respiratory
- Abdominal
What is the most valuable tool in ACS and shows changes in other conditions (I.e. PE)?
ECG
What is angina (pectoris)?
Symptomatic, reversible myocardial ischemia.
Most commonly due to coronary artery disease.
What are the features of angina?
- Constricting/heavy discomfort in chest, jaw, shoulders, neck, or arms
- Symptoms brought on by exertion
- Symptoms relieved within 5mins by rest or GTN
What is typical angina?
Angina presenting with all 3 features of angina
What is atypical angina?
Chest discomfort which meets 2 of the typical angina characteristics
What are the most important risk factors for developing CAD?
Non-modifiable:
- Age
- Gender
- Family history of CAD (MI in 1st degree relative < 55yrs)
Modifiable:
- Smoking
- Hypertension
- Diabetes
- Hyperlipidemia
- Obesity
- Sedentary lifestyle
- Cocaine use
What other parts of the history are relevant to diagnosing CAD?
- Concurrent diagnosis of CAD (I.e. stable angina, previous MI)
- Concurrent diagnosis of other atherosclerotic arterial disease (I.e. Ischemic stroke, peripheral vascular disease, renovascular disease)
- Family history of CAD or atherosclerotic arterial disease
What are the 3 main points in managing stable angina?
- Info + support
- Offer short-acting nitrate to prevent/treat episodes of angina
- Offer optimal drug treatment
What are the side effects of short-acting nitrates?
Flushing
Headache
Light-headedness
Name 3 drug classes used in the treatment of stable angina
- B-blocker or calcium channel blocker
- Combination of #1 (I.e. dihydropyridine calcium channel blocker)
- Long-acting nitrate
Name 2 drugs used for 2º prevention of cardiovascular disease?
- Aspirin (75mg daily)
2. ACE inhibitors (for those at increased risk - angina + diabetes)
What 2 procedures are used for revascularization of the heart?
- Coronary Artery Bypass Graft (CABG)
2. Percutaneous Coronary Intervention (PCI)
When is a CABG indicated?
When the patient is stable with medication but a coronary angiograph indicates L main stem disease/proximal 3-vessel disease
Does CABG or PCI have a better outcome in terms of patient survival?
CABG
Explain the CABG procedure
Attaching grafted vessels (usually from chest, leg, arm) to coronary arteries beyond the narrowing
Explain PCI procedure
Stent placement via the femoral or radial artery to open the narrowing of the coronary vessel affected
How many seconds does 1 little square on an ECG represent?
0.04s
What is the normal speed of an ECG?
25mm/s
What plane do the limb leads look at the heart in?
Vertical plane
What leads look at the heart from an inferior view?
aVF, II, III
What leads look at the heart from a lateral view?
aVL, I
What plane do the chest leads look at the heart in?
Horizontal plane
Which leads look at the septal part of the heart?
V1 + V2
Which leads look at the anterior view of the heart?
V3 + V4
Which leads look at the lateral view of the heart?
V5 + V6
What does the p-wave represent?
Depolarisation of the atria (pulse of electrical activity from SA to AV node)