Chest Pain, ACS and Myocardial Ischaemia Flashcards
Chest pain is a common presenting complaint and the spectrum of pathology ranges from non-urgent to life threatening. What leads to diagnosis?
History, clinical examinations and investigations.
SQUITARS for history taking, but time may be of the essence.
What are the different types of causes of chest pain?
Cardiac (Ischaemic or pericarditis), respiratory (pneumonia, PE), upper gastrointestinal (oesophageal reflux) or musculoskeletal (rib fracture or costal chondritis).
What is the difference between pleural/pericardial pain and lung/heart tissue pain and how do they present?
Pleural/pericardial pain is somatic and so is often sharp and well localised, worsening on inspiration/coughing/positional movement.
In contrast lung/heart tissue pain is visceral, so dull and poorly localised, worsened by exertion.
What may be the cause of non-cardiac chest pain that’s sharp, radiates to the back and is life-threatening?
Aortic dissection.
Who might present with pericarditis and what are the changes seen on an ECG?
Pericarditis is more common in adults and men and may be secondary to a viral infection.
On an ECG there will be widespread/saddle shaped ST elevation.
How does one present with pericarditis (inflammation of the pericardium)?
Present with chest pain that’s: retrosternal, sharp and localised to the front of the chest, aggravated with inspiration/ a cough / lying flat and eased with sitting up and leaning forward. A pericardial rub (coarse, harsh noise), may be heard on auscultation.
What is cardiac/ischaemic chest pain about?
Pain secondary to pathology involving the heart (coronary heart disease aka IHD). The initial primary concern is to rule out urgent, life threatening causes.
What is a pathway of pathophysiology of coronary heart disease?
Atherosclerosis - builds up over time, lipid-laden core with fibrous external cap.
Risk factors for atherosclerosis are the same as those for IHD, name some that are modifiable and not modifiable.
Modifiable: smoking, hypertension/cholesteraemia, diabetes, obesity, sedentary lifestyle.
Non-modifiable: advanced age, family history, male.
Explain stable angina.
The atherosclerotic plaque is ‘stable’ - ischaemia only when the demands of the cardiac muscle are greater than what can be delivered by the coronary arteries.
What is the typical patient history for someone with stable angina?
Dull retrosternal pain, triggered by exertion and relieved completely by rest (as well as GNT spray). It may radiate to the neck/shoulders, but the patient will not feel particularly unwell.
What does Acute Coronary Syndrome include?
Unstable angina, MI - NSTEMI & and STEMI. Each may progress to the next.
How is Acute myocardial ischaemia caused?
Atherosclerotic coronary artery disease: an atheromatous plaque ruptures with thrombus formation causing an acute increased occlusion (of an already partially occluded lumen), leading to ischaemia. The rupture leads to platelet aggregation and thrombus formation, which goes from partially to completely occlusive.
There is a spectrum of increased occlusion form a common pathophysiologic mechanism.
When will cardiac enzymes leak?
In the case of heart tissue infarction, but not if only ischaemia, as the enzymes come from necrosed muscle cells.
What is the typical patient history for someone with Unstable angina?
Similar to that of stable angina (dull, retrosternal, may radiate to shoulders/neck), but the pain occurs at rest. It may be more intense and last longer - there’s a risk of deteriorating further to a NSTEMI/STEMI.
