Chest Pain Flashcards
What are the most common causes of acute chest pain in an individual >60
Musculoskeletal inflammation ACS PE Stable angina Pleurisy (secondary to infection) Oesophagitis (GORD or hiatus hernia)
What kind of musculoskeletal inflammation may cause chest pain
Sprained muscle e.g. due to coughing
Coxsackie B infection (Bornholm’s disease)
Idiopathic costochondritis (Tietze’s syndrome)
Varicella Zoster infection -> neuropathic pain restricted to dermatome
What are less common causes of chest pain in an individual >60
Pneumothorax Anxiety Peptic ulcer disease or gastritis Myopericarditis (includes Takotsubo) Cholecystitis Acute pancreatitis Thoracic aortic dissection or aneurysm Coronary vasospasm Oesophageal spasm Boerhaave's perforation
What would the differential for chest pain be in a young female on COCP
PE
Pneumothorax (esp. tall and thin)
Cocaine-induced coronary spasm
Which causes of chest pain are potentially fatal and require immediate management?
ACS Aortic dissection Pneumothorax PE Boerhaave's perforation
What are the presenting features you might see in ACS
Sudden-onset, central, crushing pain radiation to arms/shoulders/neck/jaw, minutes-hour
History of ACS, smoking, HTN, cholesterol, DM, family history
What signs may be seen in a patient with ACS on exam
Signs of high cholesterol: xanthochromia/lasma, corneal arcus
Signs of peripheral vascular disease: weak pulse, cyanosis, cold, atrophic skin, ulcers, bruises, carotid bruits
Signs of brady or tachy arrhythmia esp on ECG
What are the presenting features you might see in aortic dissection
Sudden onset tearing chest pain that radiates to the back
Very intense from onset
History of HTN, smoking, atherosclerosis, IHD
What signs may be seen in a patient with aortic dissection on exam
Absent pulse in one arm (due to occlusion by the dissection flap)
Hypertension or hypotension
Difference in blood pressure between arms >20mmHg
New-onset aortic regurgitation
Pleural effusion (usually on let)
What are the presenting features you might see in pneumothorax
Sudden-onset pleuritic chest pain + SOB
Could also be painless breathlessness
What signs may be seen in a patient with pneumothorax on exam
Hyperinflated chest wall with reduced expansion
Hyper-resonant percussion over the affected area
Absent breath sounds over affected area
Tracheal deviation in tension pneumothorax - EMERGENCY
What are the presenting features you might see in PE
Sudden onset SOB and/or pleuritic chest pain and/or haemoptysis
Inflamed limb
Risk factors for clots e.g. surgery, malignancy, COCP, long haul flight (stasis)
What signs may be seen in a patient with PE on exam
Tachycardia
Signs of hypoxia (rare)
What are the presenting features you might see in Boerhaave’s perforation
Sudden onset severe chest pain immediately after vomiting
SOB and pleuritic pain develops after due to subsequent pleurisy and effusion
What signs may be seen in a patient with Boerhaave’s perforation on exam
Signs of pleural effusion: dull percussion, absent breath sounds, reduced resonance Subcutaneous emphysema Abdominal rigidity, swelling Fever Tahcycardia Hypotension
What tests should be ordered for suspected ACS
ECG
Bloods esp. troponin
CXR
Second line: D-dimer (If wells score >4)
What is the purpose of ECG for ACS testing
Either 2 30mins apart, or every 10-15mins with continued pain
ACS: signs of ischaemia, ST Elevation, LBBB
PE: tachycardia, right heart strain signs
What bloods should be ordered for suspected ACS and why
Troponin - 3-12 hours from onset of pain (can also do CK-MB levels)
Serum cholesterol - risk factor (ACS leads to decrease within 24h of even and levels do not return for 3 months)
FBC - anaemia that will exacerbate ischaemia, raised WCC
U&Es - Potassium (may cause arrhythmia)
Inflammatory markers - raised CRP
Capillary glucose - DM risk factor (esp. for silent MI)
Amylase - acute pancreatitis
What other than ACS may cause a rise in troponin
Coronary spasm Aortic dissection Myopericarditis Hypertrophic cardiomyopathy Severe heart failure Cardiac trauma f PE
What is the purpose of CXR for ACS testing
Erect chest radiograph to exclude pneumothorax and aortic pathology or Boerhaave’s (pneymomediastinum)
How should a STEMI be managed acutely
MONABASH Morphine (+anti emetic) Oxygen if sats low Nitrates e.g. GTN, isosorbide mononitrate for vasodilation Antiplatelets e.g. aspirin 300mg Beta blocker ACEi Statins Heparin \+ primary angioplasty or thrombolysis within 12 hours of onset
How should a NSTEMI be managed acutely
MONABASH Morphine (+anti emetic) Oxygen if sats low Nitrates e.g. GTN, isosorbide mononitrate for vasodilation Antiplatelets e.g. aspirin 300mg Beta blocker ACEi Statins Heparin Primary angioplasty if high risk
When are beta blockers contraindicated
Asthma
Heart block
Heart failure
What advice and medications should ACS patients be discharged with
Lifestyle change: smoking cessation, low-salt diet, exercise and weight loss
BP control i.e. ACEi, or CCB
Statin (or fibrates)
Diabetes control
Low-dose aspirin (life) and clopidogrel (year)
What are the complications of MI
Death Arrhythmia Rupture Tamponade Heart failure Valve disease Aneurysm Dressler's syndrome Embolism Recurrence
How does Dressler’s syndrome present
Pericarditis
Pleuritic chest pain (worse inspiration, relived lying forward)
Fever
What are the investigations for suspected Dressler’s syndrome
FBC - leucocytosis ECG - diffuse saddle-shaped ST elevation across leads without ST depression, PR depression Echo - pericardial effusion CXR - pericardial effusion Troponin - rule out MI
What is the management for Dressler’s syndrome
Analgesia
Large dose aspirin or NSAIDs/colchicine
PPIs is NSAIDs given
Aspiration (pericardiocentesis) if pericardial effusion
How are biliary colic and oesophageal spasm diagnosed
Oesophageal spasm - barium swallow and manometry
Biliary colic - Ultrasound
What are patients who develop Boerhaave’s likely to dev elop
Pleural effusion
Pneumomediastinum
Pneumothorax
Infection by GI flora -> mediastinitis and sepsis
How is Boerhaave’s treated
Antibiotic therapy and surgical repair
Why do some patients get vomiting with acute MIs
Bezol-Jarisch reflex
Infarction of the inferior myocardium irritates the diaphragm -> vomiting
What investigations should be ordered for suspected angina
Exercise tolerant test (ECG and BP monitored during increasing amounts of exercise) Stress echo (given dobutamine) Myoview scan (thallium injection) CT coronary angiography Angiography/angioplasty
What ECG changes would be expected in a patient who suffered a full-thickness inferior MI 2 years previously
The infarcted tissue no longer conducts electrical impulses
Deep, pathological Q waves
What are the ECG changes you would see over 7 days in a patient with acute STEMI
- Tented T waves within minutes (localised hyperkalaemia)
- ST elevation in affected leads with depression in reciprocal leads (24-48hrs)
- T wave inversion in 1-2 days and persists for weeks/months unless treated
- Q waves within days (permanent)
