Chest pain and management of arrhythmia Flashcards
what do you do for a man who has developed chest pain
Take a full history and examination
NEWS
what do you want to rule out for a patient with chest pain
MI - ACS
investigations for chest pain
12 lead ECG - compare it with old ECGs IV access CXR bloods - FBC, U+E, 12hr troponins, d-dimers, amylase ABG ECHO CT chest
list high risk ECG changes
transient or persistent ST elevation
>1mm ST depression
Deep T wave inversion
curveball in CXR
pneumothorax
big 3 differential diagnoses of chest pain
- ACS - STEMI, NSTEMI, unstable angina, coronary spasm
- Acute aortic syndrome - rupture, dissection, penetrating ulcer
- PE
what are the ‘smaller’ causes of chest pain
pericarditis pneumonia pneumothorax oesophageal spasm/reflux/rupture GB/pancreas MSK/mechanical/costochondritis/rib #/fibromyalgia Neuro - shingles HZV, nerve root pain psychosocial - panic attack drugs - cocaine, triptans, 5FU
initial treatment of ACS
MONA Morphine + antiemetic Oxygen if hypoxic Nitrate - SL/buccal/PO/topical/IV Aspirin - 300mg chewed
further treatment for ACS
heparin/LMWH/Clopidogrel/ticagrelor B blocker CCU angiography +- angioplasty IV GTN
stable angina
significant artery narrowing but predictable limiting symptoms
plaque rupture
unpredictable
rapid onset
sudden occlusion of arteries –> MI
stable angina approach
outpatient no rush situation medical therapy RF modification aspirin statins B blockers GTN
NSTEMI
ruptured atherosclerotic plaque
unstable symptoms
pain at rest
artery still open but severe and critical narrowing
threatening situation and significant mortality
STEMI pathophysiology
ruptured plaque
completely blocked artery and dying muscle
severe pain at rest
autonomic upset
emergency: time = muscle
immediate opening of artery required either PCI or thrombolysis
immediate rush
management of suspected ACS
hospital by ambulance 300mg aspirin unless contraindicated 12 lead ECG within 10 min arrival admitted to CCU/HDU or telemetry bed managed by specialist CVS services for drugs/PCI/CABG
why should patients be taken by ambulance with MI
ie why do people die from MI
VF
need access to defibrillator
ECG interpretation structure
rate rhythm ST T wave QRS PR, QT other funny stuff
territories in ECG
lateral
inferior
anteroseptal
lateral V5-6
high lateral I and aVL
inferior II, III and aVF
anteroseptal V1-4
what are reciprocal changes
ST depression in leads that dont have ST elevation
LBBB
wide QRS and goes down in V1
LBBB can mask ischaemia, true or false
true
RBBB
more subtle than LBBB
you can interpret RBBB ECG changes, true or false
true
cannot interpret LBBB underlying ECG changes
tall big QRS with T wave inversion
LVH and strain
think HOCM
broad QRS and up/down in V1
up - RBBB
down - LBBB
deep T wave inversion
stress induced MI
where should you look for P waves
V1 and lead II
sinus rhythm with atrial ectopics
seen in healthy people
long QT interval
need to measure it
broad and narrow complete heart block - which is worse
broad QRS complete heart block is more malignant
could drop dead at any moment
fusion beats
atria and ventricles collide at same time
seen in VT
pericarditis ECG changes
widespread ST elevation across territories with no reciprocal changes
PR depression
how can a patient with AF have a regular rhythm
pacemaker causing
broad QRS and very sharp spikes
aVR is a reference strip
if the ECG has been done properly the aVR lead should go down
what is the most likely cause of a student collapsing halfway through a teaching session
vasovagal
manage by elevating feet
what is syncope
transient loss of consciousness due to cerebral hypoperfusion characterised by a rapid onset, short duration and spontaneous complete recovery
‘not enough blood to the brain’
what is TLOC
transient loss of consciousness
group of things which syncope is one of them LOC with loss of awareness, amnesia, abnormal motor control, loss of responsiveness and a short duration
classification of syncope
reflex syncope
orthostatic hypotension
cardiac syncope
causes of reflex syncope
triggered by an event can be: vasovagal situational carotid sinus syncope atypical it is so common
causes of orthostatic hypotension
problem with autonomics can be: PD, MSA DM, amyloid, uraemia drug induced volume depletion
causes of cardiac syncope
pathology in the heart causing you to black out
can be:
bradycardia
tachycardia
tachy brady disease
structural disease - Ao stenosis, HOCM, MI, tamponade, rupture
other - PE, dissection
what is vasovagal syncope
trigger results in reflex activation and decreased cerebral blood flow and pooling of blood in peripheral arterial circulation
what are the 3 Ps of vasovagal syncope
no features suggesting other disease AND
Posture - prolonged standing or prevent by sitting
Provoking factors - pain, procedure
Prodromal features - sweats, feeling hot, blacking of vision
what is situational syncope
type of reflex syncope
clearly and consistently provoked by trigger e.g. straining, coughing, swallowing, post exertion syncope
define orthostatic hypotension
fall in SBP >20 or DBP >10 after standing 3 min
history taking for syncope
circumstances posture prior to event prodromal symptoms appearance - eyes open, pallor tongue biting (tip vs side - seizure) injuries duration of onset to return of consciousness post event confusion?
features suggestive of epilepsy
biting side of tongue head turning no memory of abnormal behaviour prior, during or after post ictal confusion unusual posturing prodromal deja/jamais vu
people who are syncopal may jerk?
yes
but doesnt look like a TC seizure
red flags for syncope
abnormal ECG heart failure TLOC on exertion FH of sudden cardiac death <40y new/unexplained breathlessness heart murmur
where can syncopal patients be referred to
TLoC clinic
after routine investigations
what investigation must everyone who has had syncope must have
ECG
what should you screen for in an ECG for syncope
conduction abnormalities - QT prolongation, pre-excitation, Brugada
structural abnormalities - hypertrophy, T wave changes
what is an r test
ECG monitoring for long periods of time
Implantable loop recorders are commonly used
not commonly as they are expensive but are very useful when they are used
machine inserted under skin
Indications for ECHO
structural disease concern
previously known heart disease
abnormal ECG
presence of murmur
DVLA at a glance
updated DVLA and driving guidance for medical professionals
advanced treatments for arrhythmias
implantable defibrillators (ICD)
cardiac resynchronisation pacemakers
radiofrequency ablation
radiofrequency ablation
common procedure
multiple venous access
catheters in the heart
diathermy or cryotherapy
indications for radiofrequency ablation
SVT
atrial flutter
AF
subcutaneous ICD
sits under the skin in the axilla and the tip is at the sternal notch
more cosmetically appealing
no need to enter venous circulation
list the investigations for working up a patient with syncope palpitations
Everyone - 12 lead ECG
Recurrent symptoms - ECG when symptomatic
Daily / short lived - 24 hour tape / r test
Less frequent symptoms - 7 day r test
Recurrent infrequent syncope - implantable loop recorder
Exertional symptoms - exercise treadmill test
Murmur, abnormal ECG, suspected HF… - ECHO
Seizures - Neurology
