Chest Pain And Acute Coronary Syndrome

Question 1

What is the mneumonic to follow when taking history from a patient ?

Answer 1

Site = location of the pain and if it radiates

Quality = how the pain feels ( sharp, dull )

Intensity = effect on patient , severity score

Timing = when it started , sudden , or gradual onset

Aggravating factors : what makes pain worse

Relieving factors : what makes pain better

S secondary symptoms = other symptoms

Question 2

What are the 4 different systems that could cause chest pain ?

Answer 2

1. Respiratory system ( inflammation of the pleura eg pneumonia , pulmonary embolism) . This causes chest pain defined as ‘ pleuritic ‘ as it is sharp , localised , hurts when breathes.
2. MSK( eg the ribs , the muscles beneath the ribs , the costal cartilages - costochondritis). This also minics pleuretic chest pain.
3. Cardiac system ( MI , Angina ( stable + unstable ) , pericarditis )
4. Gastro-intestinal ( esophagus acid reflux which creates a burning sensation running to the middle of the chest )

Question 3

What is the difference between cardiac and pleuritic chest pain ? And what conditions fall under each

Answer 3

Pleuritic chest pain is sharp , well localised ( patient can point to an exact area) , made worse when breathing in.
Inflammation of the parietal pleura of the lungs causes this chest pain. AS WELL as pericarditis and MSK problems. ( somatic )

CARDIAC PAIN : dull , poorly localised , centre of the chest. Often radiates to the shoulder and jaw. And worsens with exertion.This is caused by damage to the coronary arteries / cardiac muscle. Eg MI , Angina ( stable and unstable )

Question 4

What is pericarditis?

Answer 4

Inflammation of the pericardium.

It is a non-ischaemic cause of chest pain , that is often viral.

Present with retrosternum chest pain.

Mimics pleuritic chest pains eg sharp , localised to the front of thr chest.

Aggravated with inspiration , cough , lying flat.

Eased with sitting up and leaning forward.

Pericardial rub ( rustling noise ) may be heard.

Question 5

What is commonly found on an ECG of someone with pericarditis ?

Answer 5

Widespread Saddle shaped ST elevation that is common amongst all leads.

Question 6

What are examples of ischaemic causes of chest pain ?

Answer 6

Angina

MI

Question 7

What is the pathophysiology of ischaemic heart diseases ?

Answer 7

It is secondary toAtherosclerosis

Question 8

What are risk factors for atherosclerosis ( therefore ischaemic heart disease ) ?

Answer 8

Modifiable :

Smoking 
Hypertension
Dyslipidameia 
Diabetes 
Obesity 
Sedentary lifestyle 

Non-modifiable
Advanced age
Family history
Male sex

Question 9

What is stable angina ?

Answer 9

1. Narrowing of the coronary artery due to atherosclerotic plaque.
2. heart tissue ischaemia occurs only when metabolic demands of cardiac muscle are greater than what can be delivered via coronary arteries for example ON EXERTION ( eg exercise ).
3. Typical patient history involves : pain only occurs at exertion , relieved by rest , chest pain doesn’t last very long.

Question 10

What is acute coronary syndrome ?

Answer 10

Acute myocardial ischaemia caused by atherosclerotic coronary artery disease.

IT IS SECONDARY TO AN Athermatous plaque rupture with thrombus formation due to platlet aggregation at that particular site.

causing acute increased occlusion. This leads to ischameia . And eventually MI if there is completely occlusive thrombus.

Question 11

What are the 4 diseases that fall under ACS ?

Answer 11

1. Unstable angina
2. NONSTEMI
3. STEMI
4. MI ( where the two examples r STEMI AND NSTEMI )

Question 12

What are features of unstable angina

Answer 12

Pain occurs at REST
Pain may be more intense
Pain may last longer
Sweaty , anxious , pale

There is a risk of deteriorating further into MI

Blood test would indicate NO cardiac enzymes

ECG changes could be normal or T wave inversion or ST depression

Question 13

What are features of myocardial infarction?

Answer 13

1. Chest pain at rest , pain not going , sweaty , pallor

There are two types STEMI / NSTEMI

STEMI : if ECG shows ST elevation , do not wait for tropnin test. You need to get coronary artery open ASAP at thr cath lab. This is because there is complete occlusion or near occlusion of coronary artery.

NSTEMI : presents with ST segment depression , T wave inversion. Indicates ischaemia but we need to do troponin test tomorrow see if NSTEMI or unstable angina. If NSTEMI there would be troponin !

Question 14

How will a patient with costochondritis present ?

Answer 14

1. Tender /palpable affected costochondritis joints is a constant finding
   - pleuritic chest pain (pain worsens with a deep breath) , sharp
   - pain over the front of the upper chest