Chest Pain Flashcards
What is Stable Angina?
Chest Pain resulting from Myocardial Ischaemia that is precipitated by exertion and relieved by rest.
What is Decubitus Angina?
Symptoms of angina that occur when lying down.
What is Prinzmetal Angina?
Symptoms of Angina caused by Coronary Vasospasm.
What is Coronary Syndrome X?
Symptoms of Angina
Normal Exercise Tolerance
Normal Coronary Angiograms
How should you manage a case of Stable Angina?
Conservative - Stop smoking, lose weight, exercise
Medical - Anti-Anginals (BB/CCB), GTN Spray, risk factor reduction (aspirin, statins, ACEi)
Define Acute Coronary Syndrome.
A collection of symptoms caused by sudden reduced blood flow to the heart.
STEMI
NSTEMI
Unstable Angina
What is Unstable Angina?
Chest pain at rest due to ischaemia without Cardiac Injury (Normal Troponin)
How does ACS present?
Acute-onset, central, crushing chest pain.
Radiates to the arms/neck/jaw
Pallow
Sweating
How do you investigate suspected ACS?
ECG
Troponin
How would you use an ECG to diagnosis ACS?
STEMI
Hyperacute T Waves
ST Elevation
New-onset LBBB
NSTEMI/Unstable Angina
ST Depression
T Wave Inversion
Heart Block
AV Node involvement
Old Infarction
Pathological Q Waves
Which artery is occluded in a STEMI showing ST elevation in leads II, III and AVF?
Right Coronary Artery
Inferior STEMI
Which artery is likely occluded in a STEMI showing ST Elevation in leads V1-V5?
Left Anterior Descending
Anterior
Which artery is likely occluded in a STEMI showing ST Elevation in leads I, aVL, V5/6?
Left Circumflex
Lateral
Which artery is likely occluded in a STEMI showing ST Elevation and tall R waves in V1-3?
Posterior Descending
Posterior
How do you manage a patient with ACS?
Morphine
Oxygen
Nitrates
Antiplatelets (Aspirin & Clopidogrel)
Beta-Blockers
ACE Inhibitors
Statins
How would you manage a patient with a confirmed STEMI?
<12 Hours - PCI
>12 Hours - Coronary Angiography (Followed by PCI if indicated)
How would you manage a patient with NSTEMI/Unstable Angina?
Aspirin & Clopidogrel
Fondaparinux - if there is a low, bleeding risk
Unfractionated Heparin (If planned angiography)
Risk Stratify using GRACE Score
High Risk - GlpIIb/IIIa Inhibitor (tirofiban)
Low Risk - Conservative Management
What are the Complications of ACS?
DARTH VADER
Death
Arrhythmia
Rupture
Tamponade
Heart Failure
Valve Disease
Aneurysm
Dressler’s Syndrome
Embolism
Reinfarction
What is the difference between anticoagulants and antiplatelets?
Anticoagulants (eg. warfarin) block the activation of coagulation factors, and tend to be used in the treatment of Venous Thromboembolism.
Antiplatelets block platelet activation and tend to be used to treat Arterial Thromboembolism.
What are the causes of Pericarditis?
Idiopathic
Infective (Coxsackie B)
CTDs (eg. Sarcoidosis)
Dressley Syndrome (2-10 Weeks Post-MI)
Malignancy
How does Pericarditis present?
Shar, central chest pain
Pleuritic in nature
Relieved by sitting forward
Fever (if viral)
Pericardial Rub
Tamponade
Wide-spread saddle-shaped ST Elevation on ECG
How does symptomatic Atrial Fibrillation present?
Palpitations
Syncope
Symptoms of underlying cause (Loads)
Irregularly irregular pulse
How would you manage a patient with AF?
Haemodynamically Unstable - DC Cardioversion
Rhythm Control <48 Hours
DC Cardioversion or chemical Cardioversion (flecainide [contraindicated if Hx IHD] or amiodarone)
Rhythm Control >48 Hours
Anticogulate for 3-4 weeks then DC Cardioversion
Rate Control
Verapamil
Beta-Blockers
Digoxin
High-Risk Cha2DS2-VASC? Warfarin
What is a Supraventricular Tachycardia?
Regular, narrow-complex tachycardia with no p waves and a supraventricular origin.
AVNRT or AVRT
How would you investigate a suspected SVT?
ECG
Regular, narrow complex tachycardia, absent P-Waves
Delta Wave = Wolf-Parkinson-White AVRT
How would you manage a case of SVT where the patient is Haemodynamically Unstable?
Synchronised DC Cardioversion
How would you manage a Haemodynamically Stable patient with an SVT?
1) Vagal Manoeuvres
2) Adenosine IV
3) IV BB/ Amiodarone/ Digoxin
How would you manage a haemodynamically stable patient with an SVT and asthma, when Vagal Manoeuvres are unsuccessful?
Verapamil
Adenosine is contraindicated in asthma
What would be your Cardiac Ddx in a patient presenting with Syncope?
Vasovagal
Arrhythmia
Outflow Obstruction (HOCM, Aortic Stenosis_
Postural Hypotension
What are the clinical features of HOCM?
Jerky Carotid Pulse
Double Apex Beat
Ejection Systolic Murmur
FHx of young, sudden death
