Chest Pain Flashcards
List the differential diagnoses of chest pain.
Musculoskeletal inflammation Acute coronary syndrome Pulmonary embolism Stable angina Pleurisy Oesophagitis Pneumothorax Peptic ulcer disease Myopericarditis Aortic dissection Boerhaave’s perforation
List three differentials for chest pain that are more likely in young patients?
PE
Pneumothorax
Cocaine-induced coronary artery spasm
What are the five fatal causes of chest pain that you must rule out when taking a history?
PE Pneumothorax ACS Aortic dissection Boerhaave’s perforation
Which signs on examination could suggest that the patient has significant risk factors of cardiovascular disease?
Signs of hypercholesterolaemia – e.g. xanthelasma, xanthomata, corneal arcus
Signs of peripheral vascular disease – e.g. weak pulses, peripheral cyanosis, cool peripheries, atrophic skin, ulcers, bruits
Describe the pain experienced during an aortic dissection.
Sudden-onset, intense tearing chest pain
Radiating to the back (between the shoulder blades)
List some clinical signs that are associated with aortic dissection.
Different blood pressures in the two arms
Aortic regurgitation
Pleural effusion (due to irritation of pleura)
Describe the typical presentation of pneumothorax.
Sudden-onset pleuritic chest pain with breathlessness
Describe the typical presentation of PE.
Sudden-onset pleuritic chest pain with breathlessness
With or without haemoptysis
Patients may also have a swollen/inflamed leg (DVT)
What is the most common finding on examination of patients with PE?
Tachycardia
Describe the typical presentation of Boerhaave’s perforation.
Sudden-onset severe chest pain immediately after an episode of vomiting
What is the most important investigation to perform in a patient with chest pain?
ECG
Other than tachycardia, which other ECG sign is associated with PE?
S1Q3T3
What are the two main ECG signs associated with myocardial infarction?
ST elevation
New-onset LBBB
How long is the delay between myocardial damage and a rise in troponins?
3 hours
Describe how CK-MB is different to troponins.
They rise more rapidly following damage to the myocardium but it is less specific for cardiac damage
Returns to normal after 2-3 days
How long does it take for troponins to fall back to normal?
7+ days
Other than ACS, what else can cause a rise in serum troponins?
Coronary artery spasm Aortic dissection Myopericarditis Hypertrophic cardiomyopathy Severe heart failure PE
Why is it important to consider the patient’s renal function when interpreting troponin results?
Troponins are renally excreted – so a raised troponin in the context of renal failure may NOT be significant
Why might you measure blood glucose levels in a patient with a suspected ACS?
Diabetic patients can have ‘silent infarcts’ – MI without chest pain
Which form of imaging may be used to investigate a patient presenting with chest pain? Describe some pathological signs that you might see.
Erect CXR
Allows exclusion of pneumothorax, aortic pathology (e.g. widened mediastinum due to dissection) and boerhaave’s perforation (would cause pneumomediastinum, pleural effusion or pneumothorax)
Describe the ECG pattern of a posterior myocardial infarct.
ST depression in the anterior leads (V1-4)
Describe the management of ACS.
MONABASH
Morphine – may be given with an anti-emetic e.g. metoclopramide
Oxygen – maintain oxygen saturations of 94%
Nitrates – e.g. GTN or imdur
Anticoagulants – e.g. aspirin + clopidogrel
Beta-blockers – reduce myocardial oxygen demand
ACE inhibitors – reduce adverse cardiac remodeling + antihypertensive
Statins – control cholesterol
Heparin – can be used to reduce future thromboembolic risk
When are beta-blocker contraindicated?
Heart block
Asthma
Acute heart failure
What is the first-line treatment option for STEMI?
Percutaneous coronary intervention (GOLD STANDARD)
Thrombolysis
NOTE: this should be done within 12 hours of onset of pain (ideally within 1 hour)
