Chest Pain

Question 1

Features of cardiac chest pain

Answer 1

Central crushing
Radiating to left arm / jaw
Relief by GTN 
Can be brought on by exertion 
(2/3 atypical chest pain)
(0/3 non cardiac chest pain)

Question 2

What does GTN act on?

Answer 2

Smooth muscle

Question 3

Investigations for NSTEMI

Answer 3

FBC (anaemic to check before any antiplatelets)
Kidneys (contrast testing)
Glucose
Cholesterol 
Troponin

Question 4

Treatment of NSTEMI

Answer 4

Dual antiplatelets
- Aspirin 
- clopidogrel 
- ticagrelor 
<90% O2 sats then O2 
Morphine
Nitrates

Question 5

Treatment of NSTEMI if first lot of treatment doesn’t help

Answer 5

1. Statin (atorvastatin 80mg)
2. ACEIs
3. BBs (early)

Question 6

Why should oxygen use in chest pain be used cautiously?

Answer 6

Risk of vasoconstriction in hyperoxaemia

Question 7

What happens if a patient comes in which an NSTEMI, who is already on rivoroxaban/warfarin?

Answer 7

Just add aspirin - NOT dual

- wait for toponin before aspirin as bleeding risk goes up

Question 8

What are the driving regulations with MI?

Answer 8

4 weeks ban if no intervention

1 week ban if intervention e.g. stent

Question 9

Diagnostic criteria for ECG for STEMI

Answer 9

2mm ST elevation in chest leads or 1mm elevation in inferior leads

Question 10

What are the chest leads?

Answer 10

V1 - V6

Question 11

What is given in an MI if no way of PCI?

Answer 11

Altepase

Question 12

What should STEMI patients never be given?

Answer 12

Fondaparinaux

Question 13

What should be done if a patient presents with a fine ECG, -ve troponin and a pain that is not completely cardiac?

Answer 13

1. Repeat troponin at 12 hours
2. CXR
3. Stress test; MPS and ETT, possibly CTCA
4. Treat if think angina

Question 14

What is the commonest differential system for chest pain if not cardio?

Answer 14

GI

Question 15

Features of PE chest pain

Answer 15

Pleuritic

• sharp
• worse on inspiration

Question 16

Investigation for PE

Answer 16

Wells score
Low risk; D dimer
High risk; CTPA + V/Q scan

Question 17

Treatment of PE

Answer 17

After diagnosis made - LWMH or fondaparinux (continued for 5 days or until INR > 2 for 24 hours)
Warfarin given within 24 hours of diagnosis and continued for 3 months (unprovoked)
If on antiplatelet and no recent stent, usually stop this
With active cancer continue LWMH for 6 months
Massive PE - thrombolysis

Question 18

How long should the treatment for PE continue?

Answer 18

3 months (depends if reversible cause)

Question 19

What should be given in pregnancy for PE?

Answer 19

LWMH

Question 20

If there is FH of DVT/PE. what should be done?

Answer 20

Thrombophilia screening