Chest Pain and Acute Coronary Syndrome Flashcards
What are the causes of chest pain (classify them into groups)
Cardiac/vascular
Respiratory
MSK
Upper GI
What are the cardiac/vascular causes of chest pain
MI - myocardial infarction
Angina - myocardial ischaemia
Pericarditis
Aortic dissection
What are the respiratory causes of chest pain
Pneumonia
Pleurisy
Pneumothorax
Pulmonary embolism
What are the MSK causes of chest pain
Rib #
Costochondritis
How can you distinguish between cardiac and pleuritic chest pain
Cardiac - dull, poorly localised pain, worsened with exertion
Pleuritic (pleural/pericardial) - sharp, often well localised pain, worse with inspiration, coughing or positional movement
Patient presents with a dull, diffuse pain around the chest, what type of chest pain is it
Cardiac
Patient presents with a sharp and localised pain in the chest, what kind of chest pain is it
Pleuritic
What are the GI causes of chest pain
Reflux
Peptic ulcer disease
What is pericarditis and how does it present
Inflammation of the pericardium, often secondary to viral illness
Presents with:
A sharp, retrosternal pain, localised to the front of the chest
Aggravated with inspiration, coughing and lying flat and eased with sitting up and leaning forward
A pericardial rub may be heard on auscultation
What appears on an ECG with a patient with pericarditis
Widespread, saddle-shaped ST elevations
What are the risk factors for ischaemic heart disease
Same for risk factors for atherosclerosis
Modifiable
- Smoking, hypertension, dyslipidaemia, diabetes, obesity, sedentary lifestyle
Non-modifiable
- Advanced age, family history, male
What is stable angina
Where the heart tissue only becomes ischaemic when the metabolic demands of the cardiac muscle are greater than what can be delivered via the coronary arteries
How does stable angina present
Dull, central chest pain
Pain comes on with exertion and relieved by rest
Pain may or may not radiate to the shoulder, jaw or arm
Not typically associated with autonomic features
What is an acute coronary syndrome
Acute MI caused by atherosclerotic coronary artery disease
Atheromatous plaques rupture with a thrombus formation, causing an acute increased occlusion leading to ischaemia and potentially myocardial infarction
What diseases does acute coronary syndrome include
Unstable angina
Myocardial infarction (MI)
Non-ST elevation MI (NSTEMI)
ST elevation MI (STEMI)
How can you differentiate between unstable angina, NSTEMI and STEMI
Use a troponin assay to distinguish between unstable angina and STEMI/NSTEMI
Then use an ECG to distinguish between STEMI and NSTEMI. NSTEMI likely to have ST depression and/or T wave inversion. SETMI shows ST elevation
What is a typical patient history for unstable angina
Dull chest pain, occuring at rest
Pain may be more intense
Pain may radiate to shoulder, jaw or arm
Pain may last longer - limited duration
Worsens with exertion
Not typically associated with autonomic features
What is a typical patient history of MI
Dull, central chest pain
May radiate to shoulder, jaw or arm at rest
Increased severity of pain (when compared to angina)
Can have ANS activation, with nausea and sweating
Patient may or may not be breathless
What ECG changes are seen in both unstable angina and NSTEMI
ST segment depression
T wave flattening or inversion
How can you investigate an ACS
Use an ECG to look for ST elevation/depression, T inversion
Use invasive coronary angiogram to see if there are any occluded or stenosed coronary arteries
Troponin assay - see if the troponin level is raised
What methods are used to see where the ACS happened
ECG:
- Inferior changes - right coronary
- Anterior changes - left anterior descending
- Lateral changes - diagonal, obtuse marginal or circumflex
Invasive angiogram - identifies stenosis / occlusion / dissection in specific vessel
Echocardiogram - regional wall motion abnormalities can correlate with occlusion/stenosis territory
Which chest leads of an ECG show the anteroseptal side of the heart
C1 - C4
Which chest leads of an ECG show the lateral side of the heart
C5 and C6