Chest pain

Question 1

What are the characterisitics exam features of MI?

Answer 1

Cardiac-sounding pain:

• heavy, central chest pain they may radiate to the neck and left arm
• nausea, sweating
• elderly patients and diabetics may experience no pain

Risk factors for cardiovascular disease

Question 2

What are the characteristics of a PE?

Answer 2

• Sudden dyspnoea and pleuritic chest pain
• Calf pain/swelling
• Current combined pill user
• Malignancy

Question 3

What are the features of pericarditis?

Answer 3

• Sharp pain relieved by sitting forwards
• May be pleuritic in nature

Question 4

What are the features of GERD?

Answer 4

• Burning retrosternal pain
• Other possible symptoms include regurgitation and dysphagia

Question 5

What is boerhaaves syndrome?

Answer 5

• Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting
• The rupture is usually distally sited and on the left side
• Patients usually give a history of sudden onset of severe chest pain that may complicate severe vomiting
• Severe sepsis occurs secondary to mediastinitis

Question 6

What is the Tx of Boerhaaves syndrome?

Answer 6

• Diagnosis is CT contrast swallow
• Treatment:
  
  • is with thoracotomy and lavage (if less than 12 hours after onset then primary repair is usually feasible)
  • Surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin
• Delays beyond 24 hours are associated with a very high mortality rate

Question 7

What is the IMMEDIATE managment of acute chest pain?

Answer 7

• glyceryl trinitrate
• aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. Clopidogrel) outside of hospital
• do not routinely give oxygen, _only give if sats < 94%*_
• perform an ECG as soon as possible but do not delay transfer to hospital. A normal ECG does not exclude ACS.

Question 8

What is the referral pathway for chest pain?

Answer 8

1. current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
2. chest pain 12-72 hours ago: refer to hospital the same-day for assessment
3. chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action

Question 9

What is NICE’s recommendation for oxygen therapy in acute chest pain?

Answer 9

• Do not routinely administer oxygen
  
  • _​_monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission.
• Only offer supplemental oxygen to:
  
  • SpO2 < 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98%
  • people with COPD who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available

Question 10

What is the definition of anginal pain?

Answer 10

1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms

2. precipitated by physical exertion

3. relieved by rest or GTN in about 5 minutes

patients with all 3 features have typical angina

patients with 2 of the above features have atypical angina

patients with 1 or none of the above features have non-anginal chest pain

Question 11

What should be done if stable angina cannot be excluded by clinical assessment?

Answer 11

• 1st line: CT coronary angiography
• 2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
• 3rd line: invasive coronary angiography

Question 12

What are examples of non-invasive functional imaging?

Answer 12

1. Myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT)
2. Stress echocardiography
3. First-pass contrast-enhanced magnetic resonance (MR) perfusion
4. MR imaging for stress-induced wall motion abnormalities