Chest Pain And Acute Coronary Syndromes

Question 1

Chest pain is a common presenting complaint

Answer 1

• wide spectrum of pathogen associated with chest pain.

Therefore need to find out specifics of chest pain - and translating lay terminology into medical answers

Question 2

History taking - conservation with an agenda

Answer 2

S ite: location of the pain and if it radiates

Q uality: how pain feels (e.g. sharp, dull)

I ntensity: effect on patient, severity score

T iming: when it started; sudden or gradual onset

A ggravating factors: what makes pain worse

R elieving factors: what makes pain better

S econdary symptoms: other symptoms

Question 3

Causes of chest pain - differential diagnosis

Answer 3

MSK cause of chest pain - could be broken rib, could be costochondritis (inflammation of the costal cartilages

GI cause could be - oesophagus - rueful - burring pain running up the middle of the chest - worse after wasting

Respiratory cause - any condition that affects the plura - inflammation - e.g. pneumonia and pulmonary embolism

Cardiac cause - MI, stable or unstable angina, Pericarditis (usually a sharp well localised pain that is made worse by breathing or coughing (mimics pleuritic chest pain), cardiac tapenade

Question 4

Chest pain - cardiac - ischaemia vs pleuritic

Answer 4

Cardiac pain - dull, poorly localised, worsened with exertion

Pleuritic pain (anything that affects the surrounding plura)- sharp pain, often will localised, worse with inspiration coughing or positional movement

Pericarditis and MSK mimics pleuritic chest pain

Pericarditis can be made better by learning forward - and worse by leaning back

Question 5

Pericarditis - inflammation of the pericardium

Answer 5

More common in men and adults
Typically viral

Present with retrosternal chest pain
– Sharp, 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
On an ECG - there would be widespread ST elevation - it would be saddle shaped

Question 6

Cardiac ischaemia - chest pain

Answer 6

Pain secondary to pathology involving the heart - Ischaemic heart disease
Potentially a life-threatening cause of chest pain

Question 7

ATS - for a cause of coronary heart disease

Answer 7

Builds up over time

Question 8

Stable angina

Answer 8

Heart tissue ischaemia occurs only when metabolic demands of cardiac muscle are greater than what can be delivered via coronary arteries e.g. on exertion

An acute coronary syndrome includes -

1) Stable angina
2) Unstable angina
3) Non-ST elevation myocardial infarction (NSTEMI)
4) ST elevation myocardial infarction (STEMI)
5) Myocardial infarction —> death

Question 9

Acute coronary syndromes

Answer 9

Acute myocardial ischaemia caused by atherosclerotic coronary artery disease

Atheromatous plaque rupture with thrombus formation which causes an acute increased occlusion (in an already partially occluded lumen)

Leading

Question 10

Feartures of unstable angina

Answer 10

Typical patient history

Similar to stable angina
EXCEPT 
	Pain occurs at rest (or deteriorating symptom control) 
	Pain may be more intense 
	Pain may last longer
Risk of deteriorating further