Chest pain Flashcards
What is CVD (cardiovascular disease)?
Generally due to reduced blood flow to the heart, brain or body caused by atheroma to thrombosis. Plaques of fatty atheroma build up in different arteries during adult life.
These can eventually cause narrowing of arteries, or trigger local thrombosis (blood clot) which completely blocks the blood flow
Risk factors for CVD?
Smoking/tobacco use Poor diet High blood cholesterol High BP Lack of exercise Obese Diabetes Psychosocial stress Excess alcohol
Types of CVD?
Coronary heart disease (CHD), stroke and peripheral arterial disease (PVD)
What is Acute Coronary Syndrome (ACS)?
Refers to: unstable angina, NSTEMI and STEMI
CAD (coronary artery disease) presentation?
Silent ischaemia Stable/unstable angina pectoris NSTEMI STEMI Heart failure Sudden death
What is the presentation of ACS?
Chest pain >20 mins at rest - CENTRAL CRUSHING PAIN
New onset angina and worsening of existing angina
Angina after MI
(Atypical presentations common in >75)
What is the pathophysiology of ACS?
Acute thrombosis induced by ruptured atherosclerotic plaque -> vasoconstriction -> critical reduction in coronary blood flow
What does an ECG show in ACS?
Can be normal but does NOT exclude ACS Abnormal ECG shows: - ST depression - Transient ST elevation - T wave inversion
(Should be done in ambulance or within 10 mins of arriving at hospital)
What biomarkers are assessed in ACS?
Troponin I and T - GOLD standard
- reflects myocardial cellular damage
- raised troponin can be due to factors other than heart failure e.g. renal failure, PE, exertion
Creatine kinase is also raised
What types of imaging may be used?
Non-invasive: - 12 lead ECG - Echo - CT coronary angiography Invasive - coronary angiography (GOLD standard)
What are the GRACE and CRUSADE scores?
They are risk scores:
GRACE - for ischaemic risk
CRUSADE - for bleeding risk
Symptoms of ACS (for NSTEMI and STEMI)?
Acute central chest pain, lasting >20min,
Often associated with nausea, sweatiness, dyspnoea, palpitations
What is the immediate management of suspected ACS?
12 lead ECG Pain relief - morphine GTN 300mg Aspirin Give O2 Takes blood (including for troponin)
If ECG shows STEMI/new LBBB, how do you manage?
Assess for eligibility for repercussion therapy:
- PCI/stenting (if possible under 2 hours of symptoms onset)
- Fibrinolysis (if great than 2 hours of symptoms onset)
CABG (coronary artery bypass grating) - also a possibility
If ECG shows NSTEMI, what does this look like and how to manage?
ECG shows:
- ST depression
- T wave inversion
Also will have high troponin
Give 300mg aspirin, fondaparinux (factor Xa inhibitor)
Clopidogrel for longer term
What is the long term management of ACS?
Aspirin (75mg) for life - for secondary prevention of CVD
- with clopidogrel or ticagrelor for first 12 months (dual anti-platelet therapy)
Statins (atorvastatin 80mg) - aiming for LDL <1.8mmol/l
Beta-blocker + ACE-inhibitor (to all)
What is angina?
Discomfort in chest and/or adjacent areas (jaw, shoulder, back, arm) due to NARROWING of coronary artery (causing myocardial ischaemia)
What are the feature of angina?
- Constricting/heavy discomfort in front of chest, neck, shoulder, jaws or arms
- Symptoms brought on by exertion
- Symptoms relieved within 5 min by rest or GTN
Typical angina vs atypical ?
All 3 feature of angina present = typical
Only 2 features present = atypical
Drug treatment of stable angina?
1st line: Beta-blocker or CCB
2nd line: BOTH
3rd line: long-acting nitrate, ivabradine, nicorandil or ranolazine
GTN spray
75mg aspirin for secondary prevention of CVD
What complications can occur post MI?
Decreased contractility
- Hypotension -> decreased vessel perfusion -> ischaemia
- Potential embolism
Electrical instability
- Arrhythmias
Tissue necrosis
- Inflammation of pericardium -> pericarditis
- Loss of papillary muscles -> regurgitation
- Ventricular septal defect
What are the cardiovascular causes of chest pain?
Myocardial ischaemia
- CAD
Cardiovascular non-ischaemic
- Aortic dissection (injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart)
- Pericarditis (inflammation of heart wall)
What are the upper GI causes of chest pain?
non-cardiovascular
GORD
Gallstones
Peptic ulcer
Pancreatitis
What are the respiratory causes of chest pain?
non-cardiovascular
PE
Pneumothorax
Pleurisy
Pneumonia
What are the musculoskeletal causes of chest pain?
non-cardiovascular
Costocondritis (pain at rib junction connecting rib to sternum) Herpes zoster (shingles)
