Chest Pain

Question 1

what are the common causes of chest pain?

cardiac, MSK, vascular, respiratory, GI

Answer 1

• Cardiac : acute coronary syndrome, pericarditis.
• MSK : Costochondritis, rib fracture.
• respiratory : Lungs and pleura, pneumonia, pulmonary embolism.
• GI : oesophagus reflux disease, peptic ulcer disease.
• vascular : aortic dissection.

Question 2

how might you differentiate cardiac from respiratory causes?

Answer 2

• Respiratory may present with symptoms of temperature, cough with sputum and both cardia and respiratory causes SOB.

Question 3

what does the umbrella term acute coronary syndrome include?

Answer 3

• Unstable angina.
• MI.
• Non- ST elevated MI.
• ST elevated MI.

Question 4

how might you differentiate between cardiac vs pleuritic chest pain?

Answer 4

• usually cardiac pain from ischaemia or infarction would be visceral.
• from deeper structures like heart via visceral afferent nerves producing a dull central pain which brain is unable to localise. so maybe referred to as shoulder pain.
• worsens upon exertion.
• pleuritic pain is more somatic pain.
• originates from chest wall, pericardium and parietal pleura via somatic afferent nerves, and brain is able to locate sharp pain.
• worsens with chest movement.

Question 5

what observations may lead you to pericarditis diagnosis?

Answer 5

• inflammation of pericardium following viral infection.
• wide-spread saddle shaped ST elevation.
• Pericardial rub in heart sound.
• pain may spread to shoulder as phrenic nerve supplying pericardium enters spine at same level as shoulder innervations.

Question 6

define ischaemic heart disease.

Answer 6

• insufficient blood supply to heart muscle due to atherosclerotic disease of coronary arteries.
  spectrum of unstable angina, NSTEMI, STEMI.

Question 7

what is the reason for the different presentation of stable vs unstable angina?

Answer 7

• stable angina is caused by the partial occlusion of a coronary artery, which still allows for blood to flow in normal conditions but upon exertion there is an imbalance in supply and demand hence ischaemic symptoms.
• whereas in unstable angina it is more likely to be a complete occlusion of artery resulting in ischaemic symptoms even at rest.

Question 8

what are the stages of acute coronary syndrome pathophysiology?

Answer 8

• stable occlusion.
• plaque rupture.
• thrombus formation.
• sudden increase in occlusion : if partial NSTEMI, full STEMI.
• severity of occlusion determines the urgency and treatment, hence differentiation important!!!

Question 9

what are the differences in blood tests and ECG noticed in stable angina vs unstable and NTEMI/STEMI?

Answer 9

• in stable angina the troponins not elevated as infarction not occurred yet, ECG normal unless under exertion.
• ( in unstable angina closer to MI ) NSTEMI/ STEMI the troponins are elevated after 3 hours since infarction and ECG abnormal at rest with ST depression and T inversion.

Question 10

what does it mean when there is an evolution of ECG changes in STEMI’s?

Answer 10

• at acute MI there might be a noticeable ST elevation whereas overtime this normalises and there will be a T wave inversion and a deeper Q wave.
• weeks later the ST and T may normalise but Q wave persists, so if deep Q seen on ECG may indicate previous MI.

Question 11

what is a percutaneous coronary intervention?

where is it inserted?

Answer 11

*angioplasty with stent.
- non surgical procedure that uses catheter to place a stent in occluded blood vessel to open it up and restore blood flow.
- catheter inserted via radial artery –> brachial
artery –> axillary artery –> subclavian artery –> aorta.

*CT angiogram less invasive.