Chest pain: A guide to investigation and Managements for GPs Flashcards
What are features that make chest pain more likely to be cardiac in origin
- Age above 50 years
- Presence of risk factors for ischaemic heart disease
- Hypertension
- Hyperlipidaemia
- Diabetes mellitus
- Smoking history
- Family history (first degree relative)
- Previous ischaemic heart disease or strokes
- Peripheral arterial disease
- Exacerbation with exertion
what should you do if a clinical assessment indicates typical or atypical angina
- diagnostic testing should be offered
What should a patient who has angina be offered
- CT coronary angiography
what diagnostic tests should someone with coronary artery disease be offered
- non-invasive functional testing
- exercise ECG if there is uncertainty about whether the chest pain is caused by MI
How do you describe anginas pain
- Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms
- Precipitated by physical exertion
- Relieved by rest or glyceryl trinitrate within about five minutes.
what is the difference between typical angina and atypical angina
Typical angina is all three of these:
- Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms
- Precipitated by physical exertion
- Relieved by rest or glyceryl trinitrate within about five minutes.
Atypical angina is 2 out of 3 of these features
when is a CT coronary angiography offered to patients
Offered if clinical assessment indicates typical or atypical angina, or non-anginal chest pain is indicated but 12-lead ECG shows ST-T changes or Q waves
when is non invasive functional testing offered to patients
Offered for myocardial ischaemia if patient has confirmed CAD (eg from previous MI) and there is uncertainty about cause of chest pain, or if CT coronary angiography shows CAD of uncertain significance or is non-diagnostic.
when should invasive coronary angiography be offered
Offered as a third line test when non-invasive functional testing is inconclusive.
when is a diagnostic of stable angina confirmed
A diagnosis of stable angina is confirmed when significant CAD (≥70% diameter stenosis of at least one major epicardial artery segment or ≥50% diameter stenosis in left main coronary artery) during CT or invasive coronary angiography is found, or reversible myocardial ischaemia is found during non-invasive functional testing.
angioplasty carries..
no prognostic benefit for patients with stable angina and non high risk patterns of coronary artery disease when compared to medical therapy alone
how is aspirin used in secondary prevention
Aspirin 75 mg once daily is proved to reduce the risk of ischaemic events in secondary prevention
when is aspirin not recommended
Aspirin is not recommended for people at low cardiovascular disease (CVD) risk who are not hypertensive, as the modest reduction in CVD risk for these patients is balanced by a modest increase in the risk of serious bleeding
what treatments are used for angina
- Beta blockers are effective first line treatment for symptoms of exertional angina.
- A calcium channel blocker may be offered instead as first line treatment for stable angina.
- short acting nitrates may be used for prevention of chest pain in patients with stable angina if used immediately before planned exertion
- Consider angiotensin converting enzyme (ACE) inhibitors for people with stable angina and diabetes
what are the side effects of nitrates
- flushing
- headache
- lightheadedness
Who should get statin therapy
Statin therapy is recommended for all adults with clinical evidence of cardiovascular disease, and should be offered as soon as possible for secondary prevention of morbidity and mortality
How do you grade the severity of anginal symptoms
Canadian cardiovascular society classification (CCS)
List the grades and levels of symptoms for the Canadian cardiovascular society classification (CCS) of anginas symptoms
CCS Class I
- ordinary activity does not cause angina, angina occurs with strenuous or rapid or prolonged exertion only
CCS Class II
- Slight limitation of ordinary activity Angina on walking or climbing stairs rapidly, walking uphill, or exertion after meals, in cold weather, when under emotional stress, or only during the first few hours after awakening
CCS Class III
- Marked limitation of ordinary physical activity Angina on walking one or two blocks on the level or one flight of stairs at a normal pace under normal conditions (equivalent to 100 to 200 m)
CCS Class IV
- inanity to carry out any physical activity without discomfort or angina at rest
when can people with angina drive
Drivers with angina may continue to drive provided that symptoms do not occur at rest, with emotion or at the wheel
- drivers with acute coronary syndrome must not drive but can resume driving one week after ACS if
- percutaneous coronary intervention is successful
- no revascularisation is planned within the next 4 weeks
- the LV ejection fraction is at least 40%
when can drivers with ACS carry on driving
- percutaneous coronary intervention is successful
- no revascularisation is planned within the next 4 weeks
- the LV ejection fraction is at least 40%
how long after having a CABG can you drive
should not drive for at least four weeks
Is air travel contraindicated in chest pain
- providing angina is stable air travel is not contraindicated
- should advice patients to inform airline medical staff before flights, and avoid precipitating factors such as heavy lifting
when should you refer someone for an upper GI endoscopy
- dysphagia
- patients over 55 years old with weight loss and either upper abdomen pain, reflux or dyspepsia
what are the typical features that are suggestive of cardiac pain
- Constricting discomfort or heavy pressure in the chest, neck, shoulders, jaws, or arms, the left arm in particular
- Precipitation or exacerbation with physical exertion or emotional upset, though patients with acute coronary syndromes may experience chest pain in the absence of physical exertion or emotional stress
- Pain which may be associated with nausea, vomiting, shortness of breath and sweating
- Pain relieved by rest or glyceryl trinitrate may suggest angina. Persistent pain raises concerns regarding an acute coronary syndrome.
Name some risk factors for ischaemic heart disease
- Age above 50 years
- Hypertension
- Hyperlipidaemia
- Diabetes mellitus
- History of smoking
- Family history of ischaemic heart disease in a first degree relative
- Previous ischaemic heart disease or stroke
- Peripheral vascular disease.
What features in the history make a diagnosis of ischaemic heart disease less likely
Pain brought on or exacerbated by
- Breathing
- Swallowing
- Changing position
- Palpation of the chest wall
- Intermittent pain unrelated to exertion
- Pain which is worse after meals
- Pain described as sharp, localised or burning
- Pain localized to a specific dermatome. Herpes zoster can present as acute chest pain which may precede the onset of vesicular lesions
- Any recent history of chest trauma.
What drugs are patient offered following an myocardial infarction
- offered an aspirin plus a second anti platelet drug scubas clopidogrel or ticagrelor
- aspirin is recommended on a long term bassi following a MI and the second anti-platelet drug is usually continued for up to 12 months
who do you give an early angiography to
Early angiography (within 96 hours) is the treatment of choice for high risk non-ST elevation myocardial infarction (NSTEMI) - Evidence that a PCI carried out with 96 hours of presentation offers a better long term outcome in the context of high risk non-ST elevation MI compared to medical therapy
what does the duration of anticoagulation medication following a PE depend on
- whether the patient had a provoked or unprovoked PE
- diagnosis of cancer
- risk of bleeding
- risk of venous thromboembolism recurrence
how long is LMWH continued for pregnant women and for patients with active cancer
- for pregnant women it is continued until the end of the pregnancy
- for people with active cancer LMWH is continued for at least 6 months
with people who have a provoked PE how long is warfarin continued for
3 months
for people who have an unprovoked PE how long is warfarin continued for
- beyond 3 months following an assessment of the risks and benefits of continuing treatment
what might be the only physical sign of a PE
- sinus tachycardia
- can also have atrial fibrillation secondary to an acute PE but this is rare
What other findings on an ECG could you find in a PE
- Sinus tachycardia
- atrial arrhythmias
- right axis deviation
- right atrial hypertrophy
- right ventricular hypertrophy, or right bundle branch block.
- Rarely the classical S1-Q3-T3 combination (deep S wave in lead I, Q waves and T wave inversion in lead III) is seen.
what patients who have just given birth are particularly at risk of a PE
particularly in patients with pre-eclampsia, caesarean section, and multiple births
what is a major risk for PE
- pregnancy and the puerperium
Name some life threatneing presentations of chest pain
- Pulmonary embolism
- Acute coronary syndrome
- Aortic dissection
- Oesophageal rupture
- Perforated peptic ulcer
- Tension pneumothorax
How does pericarditis present
his usually presents with a sharp chest pain that is well localised, relieved on leaning forwards, and which may be associated with a pericardial rub heard at the left sternal edge.
- check the patients temperature as a fever over 38 degrees is a risk factor for referral to hospital
What are symptoms of aortic stenosis
- Exertional angina (35%)
- Exertional syncope (15%)
- Exertional breathlessness and heart failure (50%).
why should you be cautious in prescribing nitrates to a patient with aortic stenosis
Nitrate induced preload reduction may precipitate syncope.
why should you be cautious in prescribing ACE inhibitors in a patient with aortic stenosis
You should also avoid prescribing angiotensin converting enzyme inhibitors as afterload reduction with these and vasodilators in general may cause sudden severe hypotension.
What are the clinical features of severe aortic stenosis
- Slow rising pulse
- Narrow pulse pressure (systolic blood pressure minus diastolic blood pressure), harsh ejection systolic murmur (loudness not a guide to severity)
- A quiet or absent second heart sound, a fourth heart sound and, in left ventricular dilation and failure, you may also hear a third heart sound.
why is exercise testing contraindicated in aortic stenosis
- due to the risk of sudden cardiac death
- in mild to moderate cases, exercise testing is occasionally performed at low workload to assess functional capacity, but always under specialist supervision and with a definite clinical indication
list contraindications to exercise testing
- aortic stenosis
- hypertrophic cardiomyopathy
- recent MI within 6 weeks
- left bundle branch block on a resting ECG as it difficult to evaluate ECG changes
what is the treatment for aortic stenosis
- aortic valve replacement once symptoms start
Why is valvuloplasty not performed for aortic valve disease
- high risk of complications including stroke and aortic valve regurgitation and lack of long term benefits
when is mitral valvuloplasty used
Mitral valvuloplasty is indicated in some cases of severe mitral stenosis.
What is recommended for asymptomatic patents with mild to moderate aortic stenosis
- 6 month review with repeat echocardiography
if a patient is asymptomatic but has severe aortic stenosis what is recommended
Criteria is used which may be used to decide on further surgical management
- degree of severity
- presence of heart failure
- evidence of haemodynamic instability on exercise
- each patient should be assessed by a cardiologist
how does percutaneous aortic valve replacement now work
A stented valve is mounted on a catheter and may be placed via the transfemoral or transapical route under local anaesthesia.
