Chest pain Flashcards
Name 7 causes of acute chest pain in someone of 60 y/o
Musculoskeletal inflammation ACS PE Stable angina Pleurisy Oesophagitis Pneumothorax
A young female on the COCP may be more likely to suffer from?
PE (COCP thrombogenic)
Pneumothorax (especially if tall and thin)
Cocaine induced coronary spasm
Which conditions presenting as chest pain require immediate management?
ACS Aortic dissection Pneumothorax PE Boerhaave's perforation
What are the key features of ACS
Sudden onset central crushing chest pain radiating to either arm/neck/jaw
Lasts few minutes to 30 minutes/longer
Higher suspicion if PMH of exertion angina or MI or CVS RFs
Any signs of Brady/tachyarrhythmias
What are the signs of hypercholesterolaemia
Xanthomata
Xanthelasma
Corneal arcus
What are the signs of PVD
Weak pulses Peripheral cyanosis Cold peripheries Atrophic skin Ulcers Bruits upon carotid auscultation
Why is it important to look for signs of Brady/tachyarrhythmias
Brady/tachyarrhythmias cause drop in CO - reduced cardiac perfusion –> ischaemia
Arrhythmias commonly occur around scarred myocardium - from old infarcts but also acute infarcts (e.g. heart block/VT)
VT commonly presents as what instead of chest pain
Shock
What are the features of aortic dissection
Sudden onset tearing chest pain radiating to back
Absent pulse in one arm due to occlusion of brachiocephalic trunk or left subclavian artery
Hypertension or hypotension
Difference in BP in both arms
New onset aortic regurgitation - manifests as early diastolic murmur
Pleural effusion (common left sided) - pleural irritation due to dissected aorta
History of HTN (most important RF), smoking, atherosclerosis, recent aortic valve replacement
What are the features of pneumothorax
Sudden onset pleuritic chest pain with breathlessness (may also present as painless though)
Hyperinflated chest wall - limited expansion
Hyperresonance over affected area
Absent breath sounds over affected areas
Tracheal deviation
In tension pneumothorax, what is very important to remember
Pleural space gets gradually inflated with air -> deviates mediastinum and compress heart leading to cardiopulmonary arrest
Hence tracheal deviation away from pneumothorax requires urgent insertion of large bore cannula in MCL above 3rd rib to allow trapped air to escape
What are the features of PE (due to DVT)
Sudden onset SOB (+pleuritic chest pain + haemoptysis) and RFs for blood clots
Tachycardia
Signs of hypoxia - often clinically unseen
What are the features of Boerhaaves perforation
Very rare but associated with high mortality
Sudden onset severe chest pain immediately after vomiting
SOB and pleuritic chest pain maybe shortly afterwards
Signs of pleural effusion after some hours (dull percussion, absent breath sounds, decreased vocal resonance)
Subcutaneous emphysema?
Abdominal rigidity/sweating/fever/tachycardia/hypotension present as illness progresses but non-specific
If a patient has chest pain - what investigations should be done?
ECG
Blood tests - troponin, serum cholesterol, FBC, U&Es, inflammatory markers, capillary glucose, amylase
Imaging - erect CXR
Second line - d dimer
What are we looking for on an ECG for a patient who presents with chest pain
Look for signs of ischaemia or arrhythmias
If PE suspected, signs of right heart strain or tachycardia
Look for STEMI / new onset LBBB
What is the difference between CK-MB and troponin
Both look for damage to cardiac muscle
CK-MB falls back to normal within 2-3 days, Troponin levels remain high for over 7 days
NB troponins are really excreted so be careful when interpreting troponin levels in someone with renal failure
How do serum cholesterol levels change after an MI
Causes a decrease in total serum cholesterol, HDL and LDL within 24 hrs of infarct –> levels will not return to normal for 2-3 months post infarct
Hence measure cholesterol levels ASAP to guide future therapy
In U&Es, what should we pay particular attention to?
Potassium - this could be the cause of an arrhythmia
WCC and CRP are inflammatory markers. Raised levels of these may point to which conditions?
Pericarditis or Bornholm’s disease (ICM inflammation due to Coxsackie B virus)
Elevated CRP/WCC may also point to aortic dissection/MI
Why should you check amylase levels?
Patients who have acute pancreatitis may also present with severe central chest pain and no epigastric tenderness.
What do D-dimer levels show and why do we check it as a second line
D dimer is the breakdown product of fibrin clot - can be caused by recent surgery/trauma –> not diagnostic of PE/DVT
But low D-dimer can be used to rule out a DVT/PE
What does ST depression in V1-V3 show?
Anterior NSTEMI or posterior infarct (treated like a STEMI)
A patient has tearing pain radiating to the back, pulse and BP not equal in different arms and CXR shows wide mediastinum. What should you suspect?
How do you confirm
Aortic dissection
Confirm with CT angiography of chest or Transoesophageal echo —> looking for a false lumen
How are all patients with ACS managed acutely? (MONABASH)
- Morphine (and metoclopramide)
- Oxygen - only if required
- Nitrates for vasodilation
- Antiplatelets - aspirin + clopidogrel (ADP receptor blocker)
- Beta-blocker - reduce myocardial O2 demand. CONTRAINDICATED if patient has heart block, asthma or signs of acute HF
- ACEi - reduces A2 mediated vasoconstriction, reduces remodelling which can cause arrhythmias
- Statins - improve endothelial function and reduce cholesterol. Also modulate inflammatory responses (CRP), prevent thrombus formation
- Heparin - LMWH given or fondaparinux, prevents coronary thrombosis
STEMI patients should receive what within 12 hours of onset of pain
Thrombolysis or angioplasty - and ideally within 1 hour
angioplasty better bu time is the most important
NSTEMI patients should be given angioplasty if severe acute criteria are met. What score is given for NSTEMI patients to stratify the risk of NSTEMI
GRACE score
When do you give ACEi vs CCB vs thiazide diuretics
ACEi if less than 55 years and white, CCB/thiazide if >55 or non white
Can give a mix if one drug insufficient
If statins are not tolerated, what is given?
Fibrins
How isi thromboembolic risk decreased?
Aspirin and clopidogrel (ADP inhibitor)
What makes a patient a candidate for ICD
If EF < 35% (severe LV dysfunction)
Conduction block on ECG
What are the common complications of MI? (Darth Vader)
Death Arrhythmia Rupture (either septum or outer walls) Tamponade Heart failure Valve disease Aneurysm Dresslers Syndrome (autoimmune pericarditis) Embolism Reinfarction
What are the differences between Dresslers syndrome and simple post MI pericarditis?
Post-MI pericarditis: more common, presents within 2-4 days
Dressler’s syndrome: autoimmune pericarditis, presents 2-10 weeks after MI
What would test results show in someone with Dressler’s syndrome
Leukocytosis
ECG shows diffuse saddle-shaped ST elevation across several leads without reciprocal ST depression. May also show PR depression
ECG and CXR to exclude reinfarction/pulmonary pathology
How to treat someone with Dressler’s syndrome?
Analgesia - NSAIDS and/or colchicine. PPI to prevent gastric irritation from NSAIDS. Consider pericardiocentesis if significant pericardial effusion.
Monitor renal function closely due to NSAIDS/ACEi
How do you diagnose gallstones?
How do you diagnose oesophageal spasm?
Gallstones - using US
Oesophageal spasm - using barium swallow and oesophageal manometry (normal result doesn’t exclude it)
(May be better to do therapeutic trial - prescribe PPI and see if positive response)
MI causes reciprocal changes in ECG. What does this mean
ST elevation in some leads –> ST depression in opposite anatomical leads
If you have a tall, thin young individual, which diagnoses must you think of first?
Pneumothorax or Marfans syndrome predisposing to dissected thoracic aorta/dissected aortic aneurysm
Most cases of aortic dissection will show what on CXR
Widened mediastinum
Any aortic dissection involving the ascending aorta is classed as what type of dissection?
Wb dissections involving descending aorta?
Ascending aorta = Stanford Type A - SURGICAL EMERGENCY
Descending aorta = Type B - managed medically and only surgical if medical management fails
N&V are commonly associated with which MIs?
Inferior
N&V with a small unilateral pleural effusion indicates possibility of?
Boerhaaves syndrome
How to distinguish MI and Boerhaaves without looking at troponin etc
MI = pain precedes vomiting
Boerhaaves = vomiting precedes pain
What is the management of Boerhaaves syndrome
Prompt antibiotic therapy
Surgical repair of oesophagus with mediastinal washout
Why do inferior MIs tend to cause N&V
Infarction of the inferior myocardium irritates the diaphragm
On an ECG, how could you tell if a patient had a full thickness MI 2 years previously?
Pathological (deep) Q waves
