Chest Pain And Acute Coronary Syndromes Flashcards
What are some possible causes of chest pain that is non cardiac?
Skin
Musculoskeletal
Respiratory (Lungs and Pleura)
Gastrointestinal (Oesophagus)
Vascular (Aortic dissection)
In cardiac sources of chest pain, what may be being affected?
Heart
Pericardial sac
With cardiac chest pain, how is the pain experienced?
Centrally
What may cause cardiac chest pain?
Acute coronary syndromes
Stable angina
Pericarditis
What may cause respiratory/pleuritic chest pain?
Chest infection (pneumonia)
What symptoms would indicate pleuritic/respiratory source of chest pain? (Helps differentiate between a cardiac issue)
Cough
Temperature
Shortness of breath
Where would the pain likely be with a respiratory/pleuritic chest pain?
Lateral/anterolateral rather than central chest pain
With musculoskeletal chest pain, what is the pain like?
Well localised
Sharp
Worsened with inhaling or coughing
What are the 2 types of afferent nerves related to chest pain?
Somatic afferent nerves
Visceral afferent nerves
Why does cardiac (ischaemic) chest pain differ to pleuritic chest pain?
Have different types of innervation
Cardiac chest pain involves stimulation of visceral afferent nerves
Pleuritic chest pain involves stimulation of somatic afferent nerves
What is the type of pain experienced with cardiac chest pain?
Dull pain
Felt centrally
Poorly localised (Pain can be referred to as coming from another location like the shoulder)
What segments do the visceral afferent nerves plug into at the spinal cord which innervate the heart?
T1 - T4/T5
Why can (ischaemic) cardiac chest pain lead to pain radiating to the shoulders/arm?
Brain does no expect to receive pain signals from the visceral afferent nerves of the heart, so it gets confused and thinks its receiving signals from the somatic afferent nerves from the skin. So the patients thinks the pain is coming from the T1-T4/T5 Dermatome
What type of pain is experienced with Pleuritic chest pain?
Sharp
Well localised
No radiation
May:
-Worsen with position (pericarditis)
-Worsen with inspiration or coughing (respiratory or MSK cause)
Why is pleuritic chest pain well localised?
Supplied by somatic afferent nerves which brain expects
What type of sounding chest pain is likely if a chest pain is made worse when breathing deeply or when coughs??
There is tenderness over the left 4th intercostal cartilage
What type of cause is this?
Pleuritic sounding chest pain
MSK cause likely costochondritis
What may happen to the pericardium to cause chest pain?
Can become inflamed
PERICARDITIS (somatic afferents)
What worsens the cardiac chest pain caused by pericarditis?
Lying down
What relieves the cardiac chest pain of pericarditis?
Sitting up or leaning forward
What may be examined in a patient with pericarditis?
Can be normal
Could be Tachycardic
Pericardial rub once listened to with a stethoscope
What is a pericardial rub?
Sounds like when you put your hand over your ear and scratch the back of your hand
What would be observed in a blood test in a patient with pericarditis?
Inflammatory markers like elevated cRP
What may be observed on a an ECG of a patient with pericarditis?
Saddle shaped ST elevation which is widespread
Widespread meaning it is visible over all of the leads
How does the ST elevation seen in pericarditis different to a STEMI?
STEMI ST elevations would only be visible in the leads which view the specific section of the heart where the coronary artery is blocked causing the MI
Pericarditis would be seen over all 12 leads
Does stable angina fall in the category of Acute Coronary Syndrome?
No
What falls under the category Acute Coronary syndrome?
Unstable angina
MI
STEMI
NSTEMI
What is ischaemic heart disease?
Affects the coronary arteries
Insufficient blood supply to the heart muscle due to atherosclerotic disease of coronary arteries
How is Stable angina formed in Ischaemic Heart Disease?
Atherosclerosis of the coronary artery, slow stable build up forming a fixed atherosclerotic plaque which partially occludes the artery
How can Ischaemic heart disease develop from Stable angina (Stable chronic occulsion) to an Acute Coronary syndrome?
Atherosclerotic plaque ruptures
Thrombogenic material released
Very large thrombus forms occluding most of the artery or the whole artery
What has happened in the coronary artery in unstable angina?
Atherosclerotic plaque is unstable, it ruptures and platelets begin to aggregate
What has happened in the coronary artery in an NSTEMI?
Thrombus has formed partially occluding the artery
What has happened in the coronary artery in a STEMI?
Thrombus forms fully occluding the artery
When does a stable angina become an Acute Coronary Syndrome?
When the atherosclerotic plaque ruptures leading to thrombus formation
What is the history likely to be for an individual with Stable angina?
Pain relieved by rest
NO associated autonomic features I.e sweating or nausea
Likely to have Ischaemic Heart Disease risk factors
What is an ECG and Troponin blood test likely to be for a patient with Stable angina?
ECG = Normal/no acute changes
Troponin = zero/not elevated
What is the history likely to be for an individual with unstable angina?
Chest pain at REST
May not have associated autonomic symptoms
What is an ECG and Troponin blood test likely to be for a patient with unstable angina?
ECG = May see ST depression or T inversion
Troponin = Zero/not elevated
What is the history likely to be for an individual with an NSTEMI or STEMI?
Chest pain at rest
Autonomic features like sweating and nausea
What is an ECG and Troponin blood test likely to be for a patient with NSTEMI?
ECG = ST depression
Troponin = Elevated
What is an ECG and Troponin blood test likely to be for a patient with STEMI?
ECG = ST elevation
Troponin = Elevated
Why does angina not cause autonomic symptoms but NSTEMI/STEMI does?
The autonomic response produced as a result of cell death
Since cardiac myocytes are not dying in angina you do not get the autonomic symptoms
How can you distinguish between stable and unstable angina?
Stable angina = relieved by rest
Unstable angina = pain at rest, present when exercising and not exercising
How can you differentiate between unstable angina and an NSTEMI/STEMI?
Troponin is present NSTEMI and STEMI
Troponin is not in unstable angina
What nerve innervates the pericardium and diaphragm?
Phrenic nerve
What are the nerve roots of the phrenic nerve?
C3
C4
C5
Why may somebody feel pain in their shoulder with pericarditis?
Phrenic nerve compressed in pericardium
This is supplied by C3, C4 and C5, these are Dermatome around the shoulder
