Chest pain Flashcards
What is a differential for ST elevation in inferior ECG leads?
Aortic dissection
Which syndromes are associated with aortic dissection?
Marfan’s
Ehlers-Danlos
Turner’s
Noonan’s
Risk factors for aortic dissection?
Hypertension Trauma Pregnancy Bicuspid aortic valve Syndromes (M, E, T, N) Syphilis
Features of aortic dissection?
Tearing pain
Hyper or hypotensive depending on blood loss
Tachycardia, clammy and cold
Artery specific involvement
No / non-specific ECG changes / ST elevation in inferior leads
Associated symptoms of reflux?
Vomiting
High BMI
Positional changes in pain - worse when lying
Presentation of infective endocarditis?
Fever
Murmur
IV drug use is a risk factor
What organism is most likely to cause infective endocarditis in an IV drug user?
S. aureus
Risk factors for PE?
Immobility / surgery Previous PE History of malignancy Tachycardia Haemoptysis Signs of DVT
Dressler’s syndrome is…
Auto-immune pericarditis occurring 2-6 weeks after an MI
Presentation of Dressler’s syndrome?
Pleuritic chest pain
Pyrexia
Rubbing sound on auscultation
Pansystolic murmur
Treatments for chronic heart failure?
Loop diuretics will reduce the fluid overload
ACE-inhibitors and beta blockers improve the long term prognosis
What commonly follows inferior MI?
Atrioventricular block
Most common cause of mitral stenosis?
Rheumatic fever
Most common cause of cardiac arrest post-MI? (3-5 days)
Ventricular fibrillation (extensive coagulative necrosis and neutrophils)
Event 0-24 hours post MI?
early necrosis
Ventricular arrhythmia
HF
Cardiogenic shock
Event 1-3 days post MI?
extensive necrosis + neutrophils
Ventricular fibrillation (cardiac arrest)
Event 3-14 days post MI?
macrophages + granulation at margins
Free wall rupture
Valve rupture
LV pseudoaneurysm
Event 2 weeks-several months post MI?
contracted scar
Dressler’s syndrome
HF
Arrhythmias
Mural thrombus
Causes of cardiogenic shock?
Infarcted ventricular wall (reduced stroke volume)
Free wall rupture
How do you improve prognosis of chronic heart failure?
Beta blockers
Loop diuretics
Inferior MI commonly can lead to…
AV block
Pericarditis chest pain differential?
Worse when lying
Dressler’s syndrome symptoms?
Fever
High ESR
Pleuritic pain
Pericardial effusion
What is associated with persistent ST elevation and LV failure?
Left ventricular aneurysm
How do patients with LV free wall rupture present?
1-2 weeks post-MI Acute HF secondary to cardiac tamponade Raised JVP Pulsus paradoxus Distant heart sounds
Treatment for LV free wall rupture?
Urgent pericardiocentesis and thoracotomy are needed
Presentation of ventricular septal defect:
First week post-MI
Acute HF
Pan-systolic murmur
(Echo will differentiate between atrial mitre regurgitation which presents in a similar way)
Consequence of inferior-posterior infarction?
Acute mitral regurgitation
Cause of acute mitral regurgitation?
Ischaemia or rupture of the papillary muscle
Presentation of acute mitral regurgitation?
Acute hypotension
Pulmonary oedema
Early-to-mid systolic murmur
Treatment for acute mitral regurgitation?
Vasodilation and often surgical repair
Pericarditis postural effects?
Worse lying down
Relieved by leaning forward
Pericarditis pain profile?
Pleuritic
Worse when lying, better leaning forward
Global ‘saddle shaped’ ST elevation and PR depression indicated what?
Pericarditis (differential to MI as the ECG changes will be regional rather than global)
Features of acute pericarditis?
Pleuritic chest pain Non-productive cough, dyspnoea, flu-like symptoms Pericardial rub Tachypnoea Tachycardia
Management for pericarditis?
Immediately give all an echo
Treat underlying cause
Colchine and NSAIDs
Associated sign of Marfan’s aortic dissection?
History of other connective tissue related problems like bilateral inguinal hernias
Classic history?
Vague constricting sensation at chest, neck, jaw, arms or shoulder lasting 15 mins
Precipitated by exercise/emotional stress
Relieved by rest/nitrates in less than 5 mins
1 symptom =
Non-anginal chest pain
2 symptoms =
Atypical angina
3 symptoms =
Typical angina
What do you give adenosine for?
Supraventricular tachycardia
Exacerbating factor?
Anything that raises basal metabolic rate e.g. exercise, cold, post-meal, psychological stress
Differentials:
COPD and asthma (both have similar SOB, chest pain, inability to expand chest)
ACS = crescendo angina
Oesophageal pain from hot/acidic drink
Cardiac work =
HR x BP
How to differentiate?
What relieves symptoms?
GTN and rest relieves angina, not rubbing, cold/warm fluids or antacids
Associated symptoms of angina:
Palpitations SOB Dizziness Dysphagia Fatigue
Past medical history?
AMI
CABG/PCI
CV Res
Previous cardiac tests
Causes of myocardial ischaemia without coronary stenosis?
Aortic stenosis
Left ventricular hypertrophy (increased after load)
Microvascular dysfunction
Severe anaemia
Tests in angina:
Troponin CTCA MRI Dobutamine stress ECHO Nuclear perfusion
ECG signs of PE?
S1Q3T3
Sinus tachycardia
Signs of right heart strain
T wave inversion in the anterior leads
What is the murmur in aortic regurgitation?
Early diastolic
Causes of aortic stenosis?
Degenerative calcification William's syndrome Bicuspid aortic valve Post-rheumatic disease Subvalvular: HOCM
