Chest pain Flashcards
What can cause muscoskeletal chest pain
Sprained muscle from coughing
Bornholms disease
Idiopathic costochondritis
VZ infection
What is bornholms disease
Cocksackie B infection leading to muscoskeletal pain
What is Tietzes syndrome
Idiopathic costochondritis
How does Varicella zosta infection lead to chest pain
Causes neuropathic pain restricted to a dermatome
What gastro conditions can cause chest pain
Cholecystitis Peptic ulcer disease Pancreatitis Oesophagitis GORD Oesophageal spasm Boerhaves perforation
Cardio conditions causing chest pain
ACS Pericarditis Aortic dissection Myocarditis Aortic stenosis
What can cause a coronary vasospasm
Cocaine
What can lead to an MI two pathophysiologies
Vasospasm
Blockage in vessel
Examination findings MI
Xanthelasma Xanthomata- elbows back of hands Corneal arcus Cyanosis Weak pulses Bruits Legs look for ulcers hair loss Signs of arrythmia Signs of arrythmia or HB as can occur post MI
How can brady or tachy arrythmias lead to MI
Reduced CO
What can be lung finding of aortic dissection
Pleural effusion
Risk factors for aortic dissection
HTN
Atherosclerosis
IHD history
Recent aortic valve replacement
How is pneumothorax different from collapse
In collapse bronchus is blocked so air slowly gets absorbed into blood
How can pneumothorax just present
SOB
Do PE patients tend to show signs of hypoxia
Not normally only if massive
But can often show signs of desturation when walking
How does a boerhaves perforation present
Chest pain
Haematemesis
SOB from pleurisy
What is minimum amount of time takes for troponin to be elevated
3hrs
How long can troponin be elevated for
Over 7 days
What enzyme gets immediately elevated in MI
CK-MB
How long does CK-MB stay elevated for
2-3 days
Note- if still elevated after this then recurrent infarcts
Which patients are you wary of with elevated troponin
Renal patients as troponin should be excreted here
What should do if patient with CKD presents with MI
Regulary repeat troponin and look at trend
What can troponin also be elevated in
Note troponin equals cardiac damage Coronary artery spasm Aortic dissection-> iscahemia Myocarditis Cardiomyopathy Trauma HF
What will happen to LDH and cholesterol post MI
Drops and levels wont return to normal for a long time so must be assessed straight away if want to act on it
U&Es relevance post MI
Can cause arrythmia- potassium main concern
What conditions causing chest pain will CRP and ESR be elevated in
Costochondritis
MI
Dissection
Myopericarditis
Why is glucose so important in chest pain
T2DM can present for first time with symptom of silent MIs
What are you looking for chest pain eCXR
Dissection- mediastinum widened Boerhaaves- pneumomediastinum, effusion Pneumothorax Effusion Pneumonia
Posterior MI on ECG
V1-V3 ST depression
How would aortic dissection appear on echo
False lumen
How to diagnose a boerhaves perforation
Chest radiograph with water soluble contrast agent like gastrograffin
If patient is vomiting in MI what drug must give
Metoclopramide
When do you only give oxyfen MI
O2 sats less than 94%
When are NSTEMI patients candidates for angioplasty
Haemodynamically unstable LVD Ventricular arrythmias New mitral regurg or VSD NOT candidates for thrombolysis
What score can be done to work out future care of NSTEMI patients
GRACE
Important secondary prevention post MI
Glucose control BP control Lifestyle changes Aspirin for life and clopidogrel for 1 year ACEi for life Beta blockers for 1 year
If in HF post MI what should be given
Aldosterone antagonist- spironactalone
When can ICD be considered post MI
Sign of conduction block
LVD
Complications of MI
Death Arryhtmia Rupture Tamponade HF Valve disease Aneurysm Dressler syndrome Embolism Reinfarction
What is dressler syndrome
Autoimmune pericarditis 2-10 weeks post MI
What is most common post Mi pericarditis
In the few days following
Treatment of pericarditis
Analgesia
NSAIDS
PPI to account for great number of NSAIDS
Also monitor kidney function due to NSAIDS
Main complication of pericarditis
Pericardial effusion
How to treat pericardial effusion
Pericardiocentesis
What is important to ask about that relieves chest pain
GTN
Antacids
Chest pain that isnt relieved by GTN
Must rule out oesophageal spasm
What is an oesophageal spasm
Strong spasms of oesophagus
How to diagnose oesophageal spasm
Barium swallow
Manometry
Trial of PPIs
If suffering angina symptoms but no angio/ECG symptoms what could be diagnosis
Prinzmetal angina
What is prinzmetal angina
Random coronary artery spasm
Other names for prinzmetal angina
Coronary syndrome X
Variant angina
Cardiac tamponade on examination
Muffled heart sounds
Distended neck veins
Main problem of arotic dissections
Tamponade
Difference between pericardial effusion and tamponade
Tamponades arise from effusion when ability of heart to contract is impaired by fluid
What could cause ST elevation with no angio signs
Artery spasm
What causes coronary artery spasm
Cocaine
Which MIs cause nausea and vomiting
Inferior as irritate diaphragm
What can cause pleural effusion with severe chest pain
Boerhaves syndrome
Complications of boerhaves syndrome
Pneumomediastinum Pleural effusion Mediastinitis Sepsis Death 30%
What is it called when inferior MI causes N&V
Bezold jarisch reflex
Other than ST depression in V1-V3 in posterior MI what else can be seen
Tall R waves
Why is troponin better than CK-MB
Specific to heart muscle
What artery is involved in posterior MIs
Circumflex
Which artery can be affected in lateral MI
LAD
Circumflex
Initial investigations for angina
Exercise tolerance
Stress echocardiogram
Myoview scan
CT angio
What do you do if any of the initial tests for angina are positive
Angioplasty
Why would you do a stress echo
If patient has arthritis and cant do stress test
What is a stress echo
Patient given dobutamine to simulate stress
How will abnormal heart appear on stress echo
Normally a heart under stress will show increased motility but if not then will be hypokinetic
What is a myoview scan
Can be done on exercise bike or under induced stress with patients injected with thallium a radioactive agent and pictures with gamma camera are taken
What is normal on a myoview scan
Areas with good perfusion appear warm
What is a CTangio
CT synced up to heart beat and given contrast to view vessels. Calcium in calcified atherosclerotic plaques can be visualised and the degree of stenosis noted
ECG change seen minutes after occlusion
Hyperkalaemia- tented T waves
How long does T wave inversion last post MI
Develops 1-2 days after and persists for months after
If is ST depression or elevation in all chest leads what is affected artery
LCA
What leads are affected in left circumflex problems
I
aVL
V5
V6
Drugs used in stable angina
ACEi Statins Aspirin GTN spray Anti anginals
What are some anti-anginals
Beta blockers
CCBs
Define unstable angina
Chest pain at rest due to ischaemia but wihtout cardiac injury
What are precordial chest leads
Those on the chest
ECG changes seen in STEMI
Hyperacute T waves
ST elevation
New LBBB
Management of STEMI
Work out less than when symptoms started
If less than 12 hours do PCI if can do PCI within 120mins
If less than 12 hours and cant do PCI in 120mins do thrombolysis
If over 12 hours do angio then PCI if possible
Management of NSTEMI immediately
MONA But also give LMWH Then use GRACE score to assess risk If Low outpatient angio If high inpatient angio with possible PCI and can give DOAC
What is fondaparinux or enoxaparin
LMWH
Causes of pericarditis
Viral- cocksackie A9, EBV, mumps Bacterial CTD- sarcoidosis AIs Dressler syndrome
Rfs pericarditis
Male 20-50 Previous MI Cardiac surgery Cancer Uraemia
Where can pericarditis pain radiate
Trapezius sx
How else can pericarditis present
Tamponade
What is becks triad
Seen in cardiac tamponade
Becks triad
Distended neck veins
Low BP
Muffled heart sounds
How to manage pericarditis with tamponade
Pericardiocentesis
How to manage pericarditis
NSAID and PPI(ulcer prevention)
Colchicine
What drug can prevent chronic pericarditis
Colchicine
Complications of pericarditis
Chronic constrictive pericarditis
Tamponade and effusion
What is carotid sinus syndrome
Vasovagal syncope
Cardiac red flags in syncope
LOC during exercise
Severe valvular disease
Previous arrythmia
Concerning ECG
Signs on vasovagal syncope in history
Nausea
Pallor
Loss of hearing/vision
Light headed
How to manage vasovagal syncope
Educate on triggers
Physical counter pressure movements
What are physical counter pressure movements for vasovagal
Squatting
Isometric forearm grip
Leg crossing with buttocks and thighs tense
Complications of AF
Thromboembolism
Worsened HF
What must you do before AF cardioversion
Do TEE to see if IHD
What are options for rate control in AF
Bisoprolol
Verapamil
Digoxin
Diltiazem
What causes atrial flutter
Underlying heart disease
What causes HBs
IHD Rheumatic fever Drugs- CCB, b blockers and amiodarone Metabolic- hyperkalaemia, hypothyroid Sarcoid
Symptoms of 1st HB
Asymptomatic
Symptoms of T1 2 HB
Asymptomatic
Symptoms of T2 2 HB
Dizzy Syncope Dizzy Chest pain HF
Symptoms of T3 HB
Dizzy Syncope Dizzy Chest pain HF
What is T1 2 HB also called
Mobitz
What is T2 2 HB also called
Wenkerback
Investigations for HB
ECG Troponin K+, Ca2+ Digoxin toxicity Echo
Management for 3rd HB
Permenant pacemaker
Management for acute HB secondary to MI
IV atropine
External pacing
Complications for HB
Asystole
HF
Cardiac arrest
Long term management of SVT
Ablation
Management of VT haem stable
Amiodarone 300mg IV
Management of VT haem unstable
If pulse DC cardiovert
Causes of VT
Long QT
Electrolyte imbalances
Illicit drugs
Main symptom of VF
Unconscious
Causes of VF
MI Phaeos Electrolye imbalances Hypoxia Acid base imbalances Hyper or hypothermia LongQT or brugada
Rfs for WPW
Ebsteins anomaly Heart defect Mitral valve prolapse Marfans Aortic coarctation
Symptoms of WPW
Palpitations
Chest pain
Management of unstable WPW
DC cardiovert
Management of stable WPW
SVT management
Long term management of WPW
Ablation to remove accessory
Anti-arrythmic
Complications of WPW
Sudden cardiac death
Ablation SE
Ablation SEs
Bleeding
Infection
Pneumothorax
What is oesophagitis secondary to
GORD
Hiatus hernia
Chest pain radiating to back ddx
Dissection
Pancreatitis
Pericarditis
What can be immediate sign of MI on ECG
Hyperacute T waves
How much ST elevation must there be for a man over 40
Over 2mm
How much ST elevation must there be for a man under 40
Over 2.5mm
How much ST elevation must there be for a woman
Over 1mm
Over 1.5mm in V2/3
What must be there to confirm a STEMI
ST elevation in at least 2 leads
Meets mm guidelines
Bloods ordered in MI
FBC U&Es CRP Glucose Lipids Troponin CK-MB BNP TFTs Amylase
Other than ST elevation what may be seen on ECG
New onsent LBBB
What is lassitude
State of general unwell and tired
