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TCD Cases > Chest Pain > Flashcards

Chest Pain Flashcards

1
Q

Approximately what % of patients presenting to AandE with chest pain will have a cardiovascular aetiology?

A

25%

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2
Q

What is the most common cause of myocardial ischaemia ?

A

Coronary artery disease (atherosclerosis)

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3
Q

Give 6 other potential causes of myocardial ischaemia

A
  1. Aortic stenosis
  2. Hypertrophic cardiomyopathy
  3. Tachyarrythmias
  4. Cocaine use
  5. Anemia
  6. Thyrotoxicosis
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4
Q

What are the 2 non ischaemic cardiovascular causes of chest pain?

A
  1. Aortic dissection

2. Pericarditis

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5
Q

Name 4 upper GI conditions that may cause chest pain

A
  1. GORD (gastro-oesophageal reflux disease)
  2. Gallstones
  3. Peptic Ulcer
  4. Pancreatitis
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6
Q

Give 4 respiratory conditions that may present with chest pain

A
  1. PE
  2. Pneumothorax
  3. Pneumonia
  4. Pleurisy
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7
Q

Give a MSK differential of chest pain

A

Costochondritis

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8
Q

How is visceral pain commonly characterised?

A

Diffuse/ poorly localised

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9
Q

Which chest pain differential is associated with a very sudden onset?

A

PE

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10
Q

Chest pain described as ‘pressure, heavy, tight’ is most likely one of which two differentials?

A
  1. ACS - Acute coronary syndrome

2. GORD

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11
Q

Severe ‘ripping’ chest pain is associated with which differential?

A

Aortic dissection

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12
Q

Sharp, ‘stabbing’ chest pain commonly refers to what?

A

Pleuritic pain

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13
Q

Which differential of chest pain is associated with referred pain to the right shoulder?

A

Cholecystitis (Gallstones)

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14
Q

Which 3 chest pain differentials are most closely associated with hypotension/ syncope?

A
  1. PE
  2. ACS
  3. Aortic Stenosis
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15
Q

Give 4 differentials that can be associated with positional chest pain

A
  1. Pericarditis
  2. GORD
  3. MSK pain
  4. Pancreatitis
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16
Q

Which physical examinations are appropriate on a patient presenting with chest pain?

A
  1. CV
  2. Resp
  3. Abdo
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17
Q

What are the 3 characteristics of ‘typical’ angina?

A
  1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arm
  2. Precipitated by physical exertion
  3. Relieved by rest or GTN within around 5 minutes
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18
Q

Define atypical angina

A

Chest discomfort which meets two of the 3 characteristics of typical angina

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19
Q

Give the main risk factors associated with developing coronary artery disease? (6)

A
  1. Age
  2. Gender
  3. Diabetes
  4. Hyperlipidaemia
  5. Smoking
  6. Hypertension
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20
Q

What is a collapsing pulse primarily an indicator of?

A

Aortic regurgitation

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21
Q

Define ‘thrills’ felt on clinical examination of the chest

A

Palpable murmurs

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22
Q

What do parasternal heaves indicate on clinical examination?

A

Right ventricular hypertrophy

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23
Q

Name the first line diagnostic investigation for suspected stable angina

A

64 slice CT coronary angiography

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24
Q

What is the normal range of the PR interval on an ECG?

A

0.12-0.2 seconds

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25
Q

At what size is the QRS wave deemed to be broad complex?

A

> 0.12 seconds

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26
Q

Which 3 ECG changes can indicate the presence of coronary artery disease

A
  1. Pathological Q waves
  2. LBBB
  3. ST segment or T wave abnormalities
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27
Q

What do pathological Q waves indicate on ECG?

A

Current or prior myocardial infarction

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28
Q

What are the characteristics of pathological Q waves? (4)

A
  1. > 40ms wide
  2. > 2mm deep
  3. > 25% of the depth of the QRS complex
  4. Seen in leads V1-V3
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29
Q

What are the ECG characteristics of LBBB? (3)

A
  1. Broad QRS
  2. Deep S wave in V1
  3. No Q waves in V5/V6
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30
Q

Name the 3 main types of cardiovascular disease seen in the UK

A
  1. Coronary artery disease
  2. Stroke
  3. Peripheral artery disease
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31
Q

What are the 9 modifiable risk factors most closely associated with an individual patient’s risk of having a heart attack?

A
  1. Smoking
  2. Poor diet
  3. High blood cholesterol
  4. Hypertension
  5. Insufficient physical activity
  6. Overweight
  7. Diabetes
  8. Psychosocial stress
  9. Excessive alcohol consumption
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32
Q

The closure of which 2 heart valves cause the S1 heart sound?

A

Mitral and tricuspid valves

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33
Q

The closure of which 2 heart valves causes the S2 heart sound?

A

Aortic and pulmonary valves

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34
Q

Characterise the heart murmur: Aortic Stenosis

A

Systolic ejection murmur - crescendo-decrescendo murmur

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35
Q

In which area is an aortic stenosis murmur best heard?

A

Aortic area - 2nd intercostal space, right sternal edge

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36
Q

Characterise the heart murmur: Mitral Regurgitation

A

Pan-systolic murmur

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37
Q

To what area will mitral regurgitation radiate to?

A

Axilla

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38
Q

Characterise the murmur associated with mitral valve prolapse

A

A mid-systolic non ejection click

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39
Q

Mitral valve prolapse is commonly concurrent with which other form of valve disease?

A

Mitral regurgitation

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40
Q

Characterise the heart murmur: Aortic regurgitation

A

Decrescendo early diastolic murmur

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41
Q

Characterise the heart murmur: Mitral stenosis

A

Opening snap following by a mid diastolic rumble

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42
Q

The ‘opening snap’ extra heart sound is associated with which heart murmur?

A

Mitral stenosis

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43
Q

A systolic ejection click is associated with which heart murmur?

A

Aortic stenosis

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44
Q

A non ejection systolic click is associated with which form of heart valve disease?

A

Mitral valve prolapse

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45
Q

In which chest position are added heart sounds best heard?

A

Mitral area (5th intercostal space midclavicular line) with the patient lying in the left lateral decubitus position.

46
Q

An S3 heart sound is caused by what type of pathology?

A

Volume overload

47
Q

An S3 heart sound is most commonly associated with which medical condition?

A

Congestive Heart Failure

48
Q

An S4 heart sound is caused by what type of pathology?

A

Pressure overload

49
Q

An S3 heart sound is also referred to as what?

A

A ventricular gallop

50
Q

An S4 heart sound is also referred to as what?

A

An atrial gallop

51
Q

How should patients with acute onset chest pain be monitored before a diagnosis is made? (4)

A
  1. Track changes in pain + offer appropriate pain relief
  2. Regular ECGs
  3. Observations - including heart rate and BP
  4. Pulse oximetry
52
Q

Outline the 4 broad stages of acute coronary syndrome pathophysiology

A
  1. Acute thrombosis induced by a ruptured atherosclerotic plaque
  2. Vasoconstriction
  3. Critical reduction in coronary blood flow
  4. Clinical sequelae of ACS
53
Q

Give 2 clinical scenarios in which an ECG may be normal in a patient suffering from ACS

A
  1. Ischaemia in the circumflex territory

2. Isolated RV ischaemia

54
Q

How is the ischaemic risk of a patient with ACE evaluated?

A

GRACE score

55
Q

How is the bleeding risk of a patient with ACS evaluated?

A

CRUSADE score

56
Q

Drug treatment of ACS can be split into which 3 categories?

A
  1. Anti- ischaemic agents
  2. Antiplatelets
  3. Anticoagulation
57
Q

What are the 3 traditional anti-ischaemic agents used in the treatment of ACS?

A
  1. Beta-blockers
  2. Nitrates
  3. Calcium channel blockers
58
Q

Name 3 novel anti-ischaemic agents that have recently been introduced in clinical practise for the treatment of ACS

A
  1. Nicorandil
  2. Ivabridine
  3. Ranolazine
59
Q

Give 3 examples of P2Y12 receptor inhibitors

A
  1. Clopidogrel
  2. Prasugrel
  3. Ticagrelor
60
Q

What are the 2 classes of anti platelet agents used in the treatment of ACS patients

A
  1. Aspirin

2. P2Y12 receptor inhibitors

61
Q

Give 3 examples of indirect anticoagulants

A
  1. Unfractionated heparin
  2. LMWH
  3. Factor Xa inhibitors
62
Q

Name a factor Xa inhibitor that acts an an indirect anticoagulant

A

Fondaparinux

63
Q

Name 2 factor Xa inhibitors that act as direct anticoagulants

A
  1. Apixaban

2. Rivaroaxaban

64
Q

Give 3 examples of direct anticoagulants

A
  1. Bivalirudin
  2. Dabigatran
  3. Factor Xa inhibitors
65
Q

What are the 5 key management steps in ACS

A
  1. Clinical evaluation
  2. Diagnosis and risk assessment
  3. Drug therapy and invasive strategy
  4. Revascularisation decision
  5. Post discharge and long term management
66
Q

How will a tachycardia affect blood flow to the heart?

A

Reduced blood flow through the coronary arteries as the duration of diastole is shortened considerably

67
Q

From which anatomical structure do the coronary arteries arise?

A

Aortic sinuses

68
Q

Deoxygenated venous blood is returned to the right ventricle from the coronary system by which vessel?

A

Coronary sinus

69
Q

Give 2 examples of biomarkers that can be used to indicate myocardial necrosis in patients with ACS

A
  1. Troponins

2. Creatine Kinase

70
Q

Which troponin types are considered to be cardio-specific?

A

Troponin I and T

71
Q

Give 2 states that may lead to ‘irritable ventricular cells’ i.e. tendency to induce VF.

A
  1. Coronary artery disease

2. Electrolyte abnormalities

72
Q

Name 2 causes of cardiac scar tissue.

A
  1. MI

2. Cardiomyopathy

73
Q

What are the 3 main causes of cardiomyopathy?

A
  1. Infections
  2. Genetic conditions
  3. Coronary artery disease (CAD)
74
Q

Give 2 viruses that can potential cause cardiomyopathy.

A
  1. Coxsackie B virus

2. HIV

75
Q

What are the 3 main types of inherited cardiomyopathy?

A
  1. Hypertrophic
  2. Dilated
  3. Arrhythmogenic right ventricular cardiomyopathy (ARVC)
76
Q

Give 6 potential causes of dilated cardiomyopathy

A
  1. Genetic condition (hereditary)
  2. Viral infection
  3. Uncontrolled hypertension
  4. Valvular heart disease
  5. Alcohol excess
  6. Pregnancy
77
Q

What is the alternative name for Takotsubo cardiomyopathy?

A

Broken heart syndrome - brought about my extreme emotional or physical stress.

78
Q

Recall the 2 categories of ventricular tachycardia

A
  1. Focal

2. Re-entrant

79
Q

Give 3 electrolyte abnormalities that can cause VT

A
  1. Hyperkalemia
  2. Hypocalcaemia
  3. Hypomagnesemia
80
Q

How do patients often describe palpitations?

A

Feel as if their heart is beating out of their chest

81
Q

Recall 4 cardiac risk factors associated with development of SVT

A
  1. Inherited conditions
  2. Structural abnormalities
  3. Coronary artery disease
  4. Heart Failure
82
Q

Classify the drug: Ivabradine

A

Nucleotide gated I(f) channel blocker - serves to slow the heart rate

83
Q

Classify the drug Nicorandil

A

Potassium channel activator and NO donor

84
Q

Classify the drug Ranolazine

A

Blocks sodium dependent calcium channels

85
Q

Define Prinzmetal’s angina

A

A form of variable angina caused by vasospasm of the coronary arteries that occurs at rest. Predominantly in the early hours of the morning.

86
Q

What is cardiac syndrome X?

A

Otherwise known as microvascular angina. It is a condition where clinical signs of myocardial ischaemia are present but the coronary arteries remain patent.

87
Q

Classify the drug dobutamine

A

A positive inotropic sympathomimetic

88
Q

Give a contra-indication for the administration of dobutamine

A

Phaeochromocytoma

89
Q

Define ‘stunned myocardium’

A

Temporary, reversible cardiac muscle dysfunction secondary to some form of insult.

90
Q

List 4 potential complications that can occur with the tissue necrosis associated with an MI

A
  1. Inflammation of the myocardium leading to pericarditis
  2. Ventricular septal defects
  3. Ventricular rupture - leading to cardiac tamponade
  4. Papillary muscle rupture - leading to valvular regurgitation
91
Q

With an inferior STEMI, ST elevation is predominantly found in which leads?

A

Leads II, III and aVF

92
Q

With a posterior STEMI, ST elevation is predominantly found in which leads?

A

Leads V7-9

93
Q

With a lateral STEMI, ST elevation is predominantly found in which leads?

A

Leads V5-V6, I and aVL

94
Q

With a septal STEMI, ST elevation is predominantly found in which leads?

A

Leads V1-V2

95
Q

With an anterior STEMI, ST elevation is predominantly found in which leads?

A

Leads V3-V4

96
Q

Give 3 types of MI which are brought about by LAD lesions

A
  1. Septal
  2. Anterior
  3. Lateral
97
Q

What is the most common form of MI?

A

RCA occlusion leading to an inferior MI

98
Q

Give 2 examples of tissue plasminogen activators

A
  1. Alteplase

2. Tenecteplase

99
Q

Post MI statin therapy aims for what LDL level?

A

<1.8mmol/L

100
Q

When are Beta-blockers prescribed for LV impairment?

A

When LVEF <40%

101
Q

Give 2 examples of aldosterone antagonists

A
  1. Spironolactone

2. Eplenerone

102
Q

What is Orlistat?

A

A lipase inhibitor i.e. reduces the absorption of dietary fats. In rare cases this is used to medicated extreme obesity.

103
Q

How can left and right atrial enlargement be distinguished on ECG?

A

Right atrial enlargement - Tall tented P waves

Left atrial enlargement - Bifid P waves

104
Q

Define an ‘Osborne wave’

A

A J wave = a positive deflection at the J point (end of the QRS complex.

105
Q

What does an Osborne wave indicate on ECG?

A

Characteristic of hypothermia

106
Q

Define an Epsilon wave

A

Small positive deflection at the end of the QRS complex

107
Q

What does an Epsilon wave indicate on ECG?

A

Characteristic of arhythmogenic right ventricular dysplasia

108
Q

Where are extra heart sounds best heard?

A

In the left lateral decubitus position over the mitral area

109
Q

Excluding troponins, give 2 other potential cardiac markers

A
  1. Creatine kinase

2. Myoglobin

110
Q

Name the 2 shockable heart rhythms

A
  1. Ventricular fibrillation

2. Pulseless ventricular tachycardia

111
Q

Name the 2 non-shockable heart rhythms

A
  1. Asystole

2. Pulseless electrical activity

TCD Cases (25 decks)

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