Chest Pain Flashcards
List the differential diagnoses of chest pain.
Musculoskeletal inflammation Acute coronary syndrome Pulmonary embolism Stable angina Pleurisy Oesophagitis Pneumothorax Peptic ulcer disease Myopericarditis Aortic dissection Boerhaave’s perforation
List three differentials for chest pain that are more likely in young patients?
PE
Pneumothorax
Cocaine-induced coronary artery spasm
What are the five fatal causes of chest pain that you must rule out when taking a history?
PE Pneumothorax ACS Aortic dissection Boerhaave’s perforation
Which signs on examination could suggest that the patient has significant risk factors of cardiovascular disease?
Signs of hypercholesterolaemia – e.g. xanthelasma, xanthomata, corneal arcus
Signs of peripheral vascular disease – e.g. weak pulses, peripheral cyanosis, cool peripheries, atrophic skin, ulcers, bruits
Describe the pain experienced during an aortic dissection.
Sudden-onset, intense tearing chest pain
Radiating to the back (between the shoulder blades)
List some clinical signs that are associated with aortic dissection.
Different blood pressures in the two arms
Aortic regurgitation
Pleural effusion (due to irritation of pleura)
Describe the typical presentation of pneumothorax.
Sudden-onset pleuritic chest pain with breathlessness
Describe the typical presentation of PE.
Sudden-onset pleuritic chest pain with breathlessness
With or without haemoptysis
Patients may also have a swollen/inflamed leg (DVT)
What is the most common finding on examination of patients with PE?
Tachycardia
Describe the typical presentation of Boerhaave’s perforation.
Sudden-onset severe chest pain immediately after an episode of vomiting
What is the most important investigation to perform in a patient with chest pain?
ECG
Other than tachycardia, which other ECG sign is associated with PE?
S1Q3T3
What are the two main ECG signs associated with myocardial infarction?
ST elevation
New-onset LBBB
How long is the delay between myocardial damage and a rise in troponins?
3 hours
Describe how CK-MB is different to troponins.
They rise more rapidly following damage to the myocardium but it is less specific for cardiac damage
Returns to normal after 2-3 days
How long does it take for troponins to fall back to normal?
7+ days
Other than ACS, what else can cause a rise in serum troponins?
Coronary artery spasm Aortic dissection Myopericarditis Hypertrophic cardiomyopathy Severe heart failure PE
Why is it important to consider the patient’s renal function when interpreting troponin results?
Troponins are renally excreted – so a raised troponin in the context of renal failure may NOT be significant
Why might you measure blood glucose levels in a patient with a suspected ACS?
Diabetic patients can have ‘silent infarcts’ – MI without chest pain
Which form of imaging may be used to investigate a patient presenting with chest pain? Describe some pathological signs that you might see.
Erect CXR
Allows exclusion of pneumothorax, aortic pathology (e.g. widened mediastinum due to dissection) and boerhaave’s perforation (would cause pneumomediastinum, pleural effusion or pneumothorax)
Describe the ECG pattern of a posterior myocardial infarct.
ST depression in the anterior leads (V1-4)
Describe the management of ACS.
MONABASH
Morphine – may be given with an anti-emetic e.g. metoclopramide
Oxygen – maintain oxygen saturations of 94%
Nitrates – e.g. GTN or imdur
Anticoagulants – e.g. aspirin + clopidogrel
Beta-blockers – reduce myocardial oxygen demand
ACE inhibitors – reduce adverse cardiac remodeling + antihypertensive
Statins – control cholesterol
Heparin – can be used to reduce future thromboembolic risk
When are beta-blocker contraindicated?
Heart block
Asthma
Acute heart failure
What is the first-line treatment option for STEMI?
Percutaneous coronary intervention (GOLD STANDARD)
Thrombolysis
NOTE: this should be done within 12 hours of onset of pain (ideally within 1 hour)
Describe how NSTEMI patients should be managed.
If haemodynamically unstable – immediate angioplasty
Other NSTEMI patients should be risk stratified – high risk patients should receive angioplasty
Which scoring system allows risk stratification of NSTEMI patients.
GRACE score
Describe some lifestyle advice that should be given to a patient who has recently suffered an ACS.
Stop smoking
Reduce salt intake
Exercise
Weight loss
What are the different treatment options used to control blood pressure in patients at risk of a cardiovascular event?
ACE inhibitors - < 55 yo or white
CCBs or thiazide diuretics - > 55 yo or non-white
Which drugs may be used to reduce the thromboembolic risk in patients at risk of a cardiovascular event?
Aspirin
ADP-receptor antagonists (e.g. clopidogrel and prasugrel)
What treatment may be considered in patients with severe ventricular dysfunction and conduction block?
Implantable cardioverter defibrillator (ICD)
List some complications of MI.
DARTH VADER Death Arrhythmia Rupture Tamponade Heart failure Valvular disease Aneurysm Dressler’s syndrome Embolism Reinfarction
What is Dressler’s syndrome?
Autoimmune pericarditis that occurs 2-10 weeks after MI
NOTE: this is different from simple post-MI pericarditis (2-4 days after MI)
Describe the treatment of Dressler’s syndrome.
Analgesia
Anti-inflammatories
Pericardial effusion may need pericardiocentesis
List some rare causes of angina type symptoms.
Prinzmetal angina – angina at rest that occurs in cycles and is caused by vasospasm of the coronary arteries
Coronary syndrome X – signs associated with decreased blood flow to the heart tissue but with normal coronary arteries
Describe the Stanford criteria for aortic dissection and how this classification influences treatment choice.
Type A – ascending aorta – SURGICAL EMERGENCY
Type B – descending aorta – managed medically
What is Boerhaave’s perforation?
Perforation of the oesophagus due to forceful vomiting
Which other cause of chest pain is associated with nausea and vomiting?
Inferior MI
NOTE: this can be differentiated from Boerhaave’s perforation because in Boerhaave’s, the vomiting precedes the chest pain whereas with inferior MI the chest pain comes first
What are patients with Boerhaave’s perforation prone to developing?
Pleural effusion
Pneumomediastinum
Pneumothorax
