Chest Pain And Acute Coronary Syndromes Flashcards
What are the two main types of chest pain? What will be the site of pain?
Visceral pain: lungs and heart
Somatic pain: pleural sac and pericardial sac
What type of pain is visceral pain and what are the aggregating factors?
Dull,poorly localised
Worsened with exertion
What type of pain is somatic pain and what are the aggregating factors?
Sharp pain, often well localised
Worse with inspiration, coughing or positional movement
Chest pain may be due cardiac or non-cardiac causes. What are the two causes of cardiac chest pain?
1) non-ischaemic eg pericarditis
2) ischaemic…and infarction
Chest pain may be due cardiac or non-cardiac causes. What are some causes of no-cardiac chest pain? (4)
1) respiratory (pneumonia, pleurisy, pulmonary embolism
2) GI (reflux, peptic ulcer disease)
3) musculoskeletal (costochondritis, rib fracture)
4) aortic dissection
What is pericarditis?
Inflammation of the pericardium (more common in men and adults)
Often secondary to viral illness
How would someone with pericarditis present?
- Retrosternal
- sharp pain, localised to front of chest
- aggravated with inspiration, cough, lying flat
- eased with sitting up and leaning forward
- pericardial rub may be heard on auscultation
Cardiac (ischaemic) chest pain?
Pain secondary to pathology involving the heart (ischaemic heart disease)
What causes Ischaemic heart disease?
Atherosclerosis
When would heart tissue occur?
Only when metabolic demands of cardiac muscle are greater than what can be delivered via coronary arteries
What does an acute coronary syndrome include?
1) unstable angina
2) myocardial infarction
3) non ST elevation myocaridal infarction (NSTEMI)
4) ST elevation myocardial infarction (STEMI)
What are acute coronary syndromes?
Acute myocardial ischaemia caused by atherosclerotic coronary artery disease
-atheromatous plaque rupture with thrombus formation (and platelet aggregation) causing an acute increased occlusion (in an already partially occluded lumen) leading to ischaemia
How would a patient with unstable angina present differently from someone who has stable angina?
Pain occurs at rest
Pain may be more intense
Pain may last longer
**they are at risk of deteriorating further to NSTEMI or STEMI
How does stable angina differ in clinical examination findings from acute coronary syndromes (UA, NSTEMI, STEMI)
Stable angina:clinical examination often normal, no pain at rest
ACS: clinical examination often normal,
Patient may appear sweaty,anxious and pale,
There may/may not be clinical signs secondary to complications of cardiac tissue death (NSTEMI/STEMI) eg acute heart failure, heart mumur
What tests can be done to confirm the diagnosis of acute coronary syndrome?
ECG- changes suggestive of current ischaemia or infarct, look at ST segments, T waves +/- pathological Q waves
Bloods-troponin (presence indicates cardiac myocytes death)
Other investigations- excludes other potential diagnoses and help identify potential complications
What sort of changes in an ECG might you see if someone has a STEMI?
Patterns of infarct: ST elevation, hyperacute T waves
Localisation of changes helps to determine anatomical site: eg inferior STEMI: ST elevation seen in II, III, aVF
What changes in ECG would you see if someone had unstable angina or NSTEMI?
Patterns of ischaemia: ST segment depression, T wave flattening or inversion.
Why is troponin released? -cardiac conditions (9)
- Acute coronary occlusion or sever stenosis (atheromatous, dissection, spasm, embolism)
- myocarditis
- acute heart failure w/(w/o) valvular heart disease
- prolonged tachycardia (marathon running )
- cardiac amyloidosis
- cardiac trauma
- takotsubo syndrome
- defibrillation, CPR
- aortic dissection
Why is troponin released? (Non cardiac conditions) (11)
- acute PE
- pulmonary hypertension
- haemodynamic challenge
- systemic illness (sepsis, COPD exacerbation)
- severe anaemia
- rhabdomyolysis
- polymyositis
- seizures
- catecholamines release
- intracranial haemorrhage
- kidney failure
In what situation would you intervene on coronary arteries with stents?
If there is ACS related to plaque rupture
Or potentially a rarer case such as coronary embolus or dissection
