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
