Chest Pain and Breathlessness

Question 1

what are the 3 acute coronary syndromes?

Answer 1

unstable angina
NSTEMI
STEMI

Question 2

what is the difference between unstable angina and an NSTEMI?

Answer 2

unstable angina- partial blockage of a coronary artery, troponins normal
NSTEMI- complete blockage of a minor coronary artery, troponins elevated

Question 3

what are the ECG changes in NSTEMI?

Answer 3

may be normal but may have T wave inversion or ST depression

Question 4

what are the ECG changes in STEMI?

Answer 4

ST elevation >2mm in limb leads or >1mm in >2 contiguous chest leads

Question 5

which is the first cardiac enzyme to be raised in infarction?

Answer 5

myoglobin

Question 6

what are the main investigations in ACS?

Answer 6

ECG
serial troponins
coronary angiography
echo- assess complications of the MI

Question 7

what is the initial management of ACS in general?

Answer 7

Morphine- IV PRN for pain
Oxygen- sats 95-98
Nitrates- GTN or IV
Aspirin- 300mg STAT

STEMI- DAPT (aspirin and ticagrelor/prasugrel (if going for primary PCI) and primary perctuaneous coronary angiography (PCI)

Question 8

what is the initial management of NSTEMI/unstable angina?

Answer 8

dual anti platelet therapy (aspirin and ticagrelor/prasugrel) plus fondaparinux

Question 9

what is the initial management of STEMI?

Answer 9

DAPT- aspirin and ticagrelor/prasugrel (prasugrel preferred if going straight for primary PCI)
urgent primary percutaneous coronary angiography (PCI)

Question 10

what are the symptoms of left and right sided heart failure?

Answer 10

left- pulmonary oedema, crackles, SOB, paroxysmal nocturnal dysponea/ orthopnea
right- raised JVP, peripheral oedema- ankle swelling, acites

Question 11

what are the signs of heart failure on a chest X-ray?

Answer 11

A- Alveolar oedema- bat wing sign 
B- kerley B lines 
C- cardiomegaly- >50%
D- dilated upper lobe vessels 
E- pleural effusions

Question 12

what is the management of heart failure?

Answer 12

diuretics (furosemide)- to reduce fluid
oxygen/ ventilation
once stable- beta blockers (bisoprolol), ACEi (ramipril)

Question 13

what is the management of angina?

Answer 13

beta blockers- bisoprolol
GTN spray- relieves symptoms
aspirin- prevention of ACS/ stroke
surgery- bypass or PCI if symptoms uncontrolled

Question 14

what are the stages of hypertension?

Answer 14

stage 1- clinic reading >140/90, ambulatory >135/85
stage 2- clinic reading >160/100, ambulatory >150/95
stage 3 clinic reading >180/120

Question 15

what is the treatment for hypertension over 55s or those from black African or African carribean origin?

Answer 15

step 1: calcium channel blocker (amlodipine)
step 2: ACEi (ramipril), ARB (Losartan) or thiazide like diuretic (indapamide)
step 3: ACEi or ARB plus calcium channel blocker plus thiazide like diuretic

Question 16

what is the treatment for hypertension for under 55s or people with type 2 diabetes?

Answer 16

step 1: ACEi or ARB
step 2: calcium channel blocker or thiazide like diuretic
step 3: ACEi or ARB plus calcium channel blocker plus thiazide like diuretic

Question 17

what are the signs of AF on an ECG?

Answer 17

absent p waves
narrow complex tachycardia
irregularly irregular rhythm

Question 18

what is the treatment of atrial fibrillation?

Answer 18

rate control (beta blocker or calcium channel blocker) or rhythm control (cardioversion- electrical or pharmacological (amiodarone) or long term (beta blocker))
anticoagulation- if stroke risk outweighs bleeding risk warfarin or DOAC

Question 19

what is the gold standard investigation for valvular heat disease?

Answer 19

echocardiography

Question 20

what are the treatments for valve disease?

Answer 20

valvuloplasty (stenosis) 
valve replacement (stenosis pr regurgitation)

Question 21

what are the ECG signs in first degree heart block?

Answer 21

fixed prolonged PR interval >200ms/ 5 small squares

Question 22

what are the ECG signs in second degree heart block (type 1 and 2)?

Answer 22

type 1- progressive prolongation of PR interval until a QRS is dropped
type 2- consistent PR interval with intermittently dropped QRS complexes

Question 23

what are the ECG signs in complete heart block?

Answer 23

presence of P waves and QRS complexes which have no association with each other

Question 24

which leads are associated with which aspects of the heart?

Answer 24

inferior- II, III and aVF
lateral- I, aVL, V5 and V6
anterior- V1, V2, V3 and V4

Question 25

which coronary artery is associated the anterior leads?

Answer 25

left anterior descending artery

Question 26

which coronary arteries are associated with the inferior leads?

Answer 26

right coronary artery or left circumflex artery

Question 27

which coronary arteries are associated with the lateral leads?

Answer 27

left circumflex artery or diagonal branch of left anterior descending artery

Question 28

what are the ECG signs of SVT?

Answer 28

regular narrow complex tachycardia usually 140-280 bpm

Question 29

how is acute asthma graded?

Answer 29

moderate- peak expiratory flow rate (PEFR)- 50-75% of expected severe- (PEFR)- 33-50% predicated, RR >25, HR >110, unable to complete sentences life threatening- PEFR-<33%, SATS <92%, becoming tired, no wheeze, haemodynamic instability

Question 30

what is the gold standard investigation for PE?

Answer 30

CT pulmonary angiography

Question 31

what is the initial management for PE?

Answer 31

Apixaban or rivaroxaban | thrombolysis if massive PE with hypotension- altepase or streptokinase

Question 32

what do spirometry tests show in COPD?

Answer 32

obstructive picture FEV1 reduced, FVC normal FEV1/FVC ratio <0.7

Question 33

what are the components of a trilogy inhaler?

Answer 33

``` long acting beta-2 agonist (LABA) long acting muscarinic agonist (LAMA) inhaled corticosteroid (ICS) ```

Question 34

what are the optimum sats to aim for in someone with COPD?

Answer 34

88-92

Question 35

what is the scoring system for an acute exacerbation of COPD?

Answer 35

DECAF score

Question 36

what is the scoring system used for pneumonia in the hospital?

Answer 36

CURB65

Question 37

what are the scoring systems used for strep throat?

Answer 37

FEVERpain or centor

Question 38

what's the difference between type 1 and type 2 respiratory failure?

Answer 38

type 1- hypoxia | type 2- hypoxia and hypercapnia

Question 39

what are the spirometry results in restrictive lung disease?

Answer 39

FEV1 and FVC reduced | FEV1/FVC ratio >70%

Question 40

which conditions produce a raised TLco in diffusing capacity tests?

Answer 40

asthma | extra pulmonary restriction- obesity, PE, kyphoscoliosis

Question 41

which conditions produce a reduced TLco in diffusing capacity tests?

Answer 41

COPD | interstitial lung disease

Question 42

what is the treatment of an infective exacerbation of COPD?

Answer 42

``` Oxygen steroids antibiotics nebulised salbutamol non-invasive ventilation- if severe ```