Chest pain Flashcards
What is stable angina?
Give 3 rare types of angina.
- Chest pain from myocardial ischaemia, precipitated by exertion and relieved by rest.
- Decubitus angina: symptoms when lying down
- Prinzmetal angina: symptoms caused by coronary vasospasm
- Coronary syndrome x: angina symptoms with normal exercise tolerance and normal angiograms
Give 3 conservative and 3 medical management steps for stable angina.
- Stop smoking, lose weight, exercise
- Anti anginas: BB/ CCB
- Symptomatic: GTN
- Risk factor reduction: aspirin, statins, ACEi
What are the 3 constituents of acute coronary syndrome?
- Unstable angina pectoris: chest pain at rest due to ischaemia without cardiac injury.
- NSTEMI
- STEMI
Give 4 symptoms/ signs of acute coronary syndrome.
- Central crushing chest pain
- Radiates to arm/ neck/ jaw
- Pallor
- Sweating
Give two ECG signs of STEMI apart from ST elevation
Give another ECG sign of NSTEMI.
Give a sign of an old infarct on an ECG.
Give a blood test to assess for myocardial injury.
- Hyperacute T waves, new onset LBBB
- T wave inversion
- Q wave.
- troponin
Give the occluded vessel and reflective ECG leads for the following sites of infarct:
- Inferior
- Anterior
- Lateral
- Posterior
- Right coronary artery: II, III, aVF
- Left anterior descending: V1- V5
- Left circumflex: I, aVL, V5, V6
- Posterior descending: Tall R wave + st depression in V1-3
Give the acronym for general ACS management and what is stands for.
MONABASH
- Morphine
- Oxygen
- Nitrates
- Antiplatelets (Aspirin and clopidogrel)
- Beta-blockers
- ACE inhibitors
- Statins
- Heparin
What is the aim of STEMI treatment?
What is the management if a patient presents <12 hours from onset of symptoms?
What is the management if patient presents >12 hours from onset of symptoms?
- Coronary reperfusion either by PCI or fibrinolysis.
<12 hours: Send to cathlab for Percutaneous Coronary Intervention if it can happen within 2 hours of fibrinolysis administration .
>12: Coronary angiography followed by PCI if indicated.
Give 3 immediate management steps for NSTEMI/ Unstable Angina pectoris
- Aspirin+ other antiplatelet
- Fondaparinux- if low bleeding risk unless coronary angiography planned within 24hrs of admission
- Unfractionated heparin (UFH) if coronary angiography planned.
What scoring system stratifies ACS risk?
What is management for a patient presenting as high risk?
- GRACE score
High risk management: - GlpIIb/IIIa inhibitor: tirofiban
- Coronary angiography within 72 hours.
What DARTH VADER stand for in complications of ACS?
- Death
- Arrhythmia
- Rupture
- Tamponade
- Heart failure
- Valve disease
- Aneurysm
- Dressler’s syndrome
- Embolism
- Reinfarction
What is the difference in purpose of anti platelets and anticoagulants?
Anticoagulants used in:
- Venous stasis - activation of coagulation factors- causing DVT/ PE.
Antiplatelets used in:
- Vessel wall injury- platelet activation, arterial thrombosis, e.g. MI, stroke.
Give 4 causes for pericarditis other than idiopathic.
- Infective: e.g. Coxsackie B
- Connective tissue disease, e.g. Sarcoidosis
- Dressler syndrome: 2-10 weeks after MI
- Malignancy
Give 6 symptoms/ signs of pericarditis
- Sharp central chest pain
- Pleuritic
- Relieved by sitting forward
- Fever/ flu-like symptoms if viral
- Pericardial friction rub
- Tamponade if pericardial effusion
What is seen in ECG for pericarditis?
What is seen in CXR for pericarditis?
ECG: Widespread saddle-shaped ST-elevation- i.e. in various leads
CXR: pericardial effusion
What is the rhythm and rate control management of atrial fibrillation?
Rhythm control
- <48 hours: DC cardio version or chemical cardio version: flecainide or amiodarone)
- Flecainide is contraindicated if there is history of IHD.
- > 48 hrs: anticoagulant for 3-4 weeks before attempting cardioversion.
Rate control:- Verapamil, Beta-blockers, Digoxin
What is the stroke risk stratification tool?
What medication is used for high risk patients?
- CHA2DS2- Vasc score
- High risk: give warfarin
What is the definition of supraventricular tachycardia?
What is AVNRT?
What is AVRT?
- Regular, narrow-complex tachycardia with absent P waves and supra ventricular origin.
AVNRT: local circuit around AV node.
AVRT: re-entry circuit between atria and ventricles due to accessory pathway: Bundle of Kent
Give 3 ECG signs of supra ventricular tachycardia.
Differentiate post SVT termination ECG findings for AVNRT and AVRT
What is Wolff-Parkinson-White syndrome?
- Regular, narrow ECG complex, absent p waves
Post termination of SVT:
- AVNRT: normal
- AVRT: delta wave: slurred upstroke on QRS.
Presence of accessory pathway resulting in delta wave on ECG is WOLFF-PARKINSON-WHITE syndrome
Give the 4 management flowchart-like steps for Supraventricular tachycardia.
What medication involved is contraindicated in asthma? What is the alternative
- Haemodynamically unstable: synchronised DC cardioversion
- Haemodynamically stable: vagal manouvres
- IV adenosine 6mg -> 12mg ->12 mg again
- Choose from IV B-blocker, IV amiodarone, IV digoxin, Synchronised DC cardioversion
Adenosine contraindicated in asthma, give Verapamil instead
Define syncope.
Give 4 differential diagnoses of syncope
- Loss of consciousness due to hypo perfusion of brain
- Vasovagal: increased vagal discharge, drop in BP and HR. Can be precipitated by situation, e.g. sight of blood.
- Arrhythmia: low output, may have palpitations before collapse.
- Outflow obstruction: HOCM, aortic stenosis
- Postural hypotension: failure to compensate for drop in blood pressure. Caused by medications and dehydration.
Give 4 clinical features of hypertrophic obstructive cardiomyopathy.
- Jerky carotid pulse
- Double apex beat
- Ejection systolic murmur
- Family history of sudden death at young age (<65).
OSCE tip, what should you ask about if a diabetic patient has had a collapse?
- Ask about missed meals/ inappropriate insulin dosing.
