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Med 1 Block > Chest pain workshop > Flashcards

Chest pain workshop Flashcards

1
Q

What are the differential causes of non-cardiac chest pain?

A

Trauma
Malignancy
FORD
MSK - costochondritis
Pleurisy
Pneumothorax
PE

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2
Q

What is meant by cardiac chest pain?

A

Severe central/left sided crushing pain in chest
May radiate to the left shoulder/jaw
May be accompanied with SOB, nausea or lightheadedness

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3
Q

What are the common differentials of cardiac chest pain?

A

Vascular - thoracic aortic aneurysm, thoracic aortic dissection
Valvular - aortic stenosis
Pericardial - pericarditis, myocarditis
Cardiac - stable angina, acute coronary syndrome

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4
Q

Describe the process of atherosclerosis formation

A
  1. Endothelial damage and immune response - wbc migrate to site, accumulate and cause inflammation
  2. Fatty streak formation - macrophages phagocytose cholesterol to form foam cells, dead foam cells gather, inflammation cycle
  3. Plaque growth - fibrous cap grows over plaque, growing plaque narrows the lumen
  4. Plaque rupture or erosion - blood clot forms due to rupture or erosion, stops blood flow = MI or stroke.
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5
Q

What are some non-modifiable risk factors for atherosclerosis?

A

Increasing age
Family history of CVD (MI in first degree relatives M<55 F<65)
Gender - male
Ethnicity - African carribean

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6
Q

What are the medical risk factors for atherosclerosis?

A

Diabetes (hyperglycemia and dyslipidaemia)
Hypertension
Dyslipidaemia - High LDL low HDL
Metabolic syndrome

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7
Q

What are the key life-style risk factors for atherosclerosis?

A

Smoking or tobacco use
High saturated fat diet
Lack of physical activity

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8
Q

What are some key complications of atherosclerosis?

A

Ischaemic heart disease
ACS
Mesenteric ischaemia
Peripheral artery disease
Renal artery stenosis
Stroke
TIA

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9
Q

What is the key difference in a history between stable and unstable angina?

A

Unstable - brough on at rest e.g lying down, eating - not predictable Stable - predictable, after a certain level of exertion.

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10
Q

What are the triad of clinical factors that indicate stable angina?

A

Cardiac sounding chest pain
Brough on by exertion - often reproducible and predictable
Relieved by rest/GTN spray.

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11
Q

What bedside investigations may be done for a patient with stable angina as a differential?

A

Obs - (BP in both arms - rule out aortic dissection)
ECG - ST elevation/depression
SCORE - QRISK2

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12
Q

What is the purpose of a QRISK2 score in stable angina?

A

Is risk >10% mortality of CVD within next ten years start on statin.

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13
Q

What are some key factors considered within the QRISK3 score?

A

About the patient - age, sex, ethnicity, post code
Clinical info - smoking, DM, angina/MI in first degree relative ,60yrs, CKD, A,fib, HTN, migraine, RA, SLE, mental illness, antipsychotic medication, steroids, erectile dysfunction, lipid profile, BMI

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14
Q

According to QRISK3 which modifiable factor has the greatest affect on a persons risk of cardiovascular disease morality?

A

Smoking

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15
Q

What bloods should be taken in a patient with stable angina as a differential diagnosis?

A

FBC
U+Es
Lipids
HbA1c / random glucose
Troponin

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16
Q

What imaging should be ordered for a patient with stable angina as a differential diagnosis?**

A

Elective CT angiogram (extent of damage)

17
Q

What conservative management should be offered to patients with stable angina?

A

Lifestyle changes - smoking cessation, weight loss, increase exercise, improve diet.

18
Q

What medical management should be offered to patients with stable angina?

A

Beta blocker (bisoprolol) - reduce HR hence oxygen demand and inc filling of coronary arteries
Calcium channel blocker - amlodipine - reduce contractility hence oxygen demand
GTN spray (symptom relef)
Aspirin 75mg - reduce risk of thromboembolism causing MI
Atorvastatin
Diabetes control - may also consider using ACE-I instead of BB/CCB

19
Q

What surgical management should be offered to patients with stable angina?

A

Recanalization - angioplasty (drug coated balloon/drug eluting stent - useful in single vessel disease
Coronary artery bypass grafting (CABG) - multiple vessel disease or complete occlusion.

20
Q

What is the basic physiology underpinning angina?

A

Coronary blood flows only during diastole
Increase in cardiac work - inc sympathetic activity - inc HR - dec time in diastole - inc contraction force - inc vessel clsoure
Less blood supply/less oxygen within coronary artery leads to cardiac ischemia/pain
Reduced cardiac efficiency
Due to permanent blockage coronary arteries are constantly dialted to deliver O2 have no reserve when O2 demand increases.

21
Q

How does acute coronary syndrome present?

A

Cardiac sounding chest pain (may radiate to L arm/jaw + unpredictable (occurs at rest) does not respond well to GTN spray

22
Q

What are the three subcategories of conditions within acute coronary syndrome?
How to differentiate between them?

A

Unstable angina - no ST elevation, no trop rise
NSTEM - trop rise, no ST elevation
STEMI - widespread ST elevation and trop rise.

23
Q

What is the key difference between a STEMI and an NSTEMI?

A

STEMI - completely occlusive atheromatous plaque - widespread ST elevation - full thickness infarction

NSTEMI - partially occlusive athermoatous plaque - subtotal cardiac infarction - only some cardiac death - does not mess up the electrical pathway.

24
Q

What is the key way to recognise a STEMI on an ECG?

A

Tomb stone appearance

25
Q

What are the key signs of pericarditis on an ECG?

A

Saddle shaped ST elevations throughout the ECG
Typically, no inverted T waves, no presence of Q waves.

26
Q

What is the management of acute MI?

A

MONA
Morphine - 2.5 to 10mg (+anti-emetic)
Oxygen - to achieve target saturations (do not give if sats fine)
GTN - vasodilation of collateral vessels
Aspiring 300mg - prevents further thrombus formation.

If STEMI - urgent PCI
IF NSTEMI/UA - GRACE score.

27
Q

What is meant by percutaneous intervention?

A

Invasive procedures to increase blood supply to the heart by dilating the blood vessels
Includes coronary angioplasty/stenting.

28
Q

What scoring systems is used to determine the management plan of NSTEMI/UA?

A

GRACE score

29
Q

What is the conservative management for sub-acute/chronic acute coronary syndrome?

A

Telemetry monitoring - high risk of cardiac arrest in sub-acute period
Smoking cessation
Cardiac rehab

30
Q

What is the medical management of sub-acute/chronic MI?

A

Clopidogrel
Ramipril
Aspirin 75mg
Beta blocker
Statin

CRABS

31
Q

What ECG rhythms indicate a cardiac arrest?

A

Ventricular Tachycadria
Ventricular fibrillation
Pulseless electrical activity
Asystole

32
Q

What cardiac arrest rhythms are shockable?

A

Ventricular fibrillation
Pulseness ventricular tachycardia.

33
Q

How do differentiate between MSK pain and cardiac pain on physical examination>

A

Press on the chest, between the ribs - this will exacerbate MSK pain, will not effect cardiac pain.

34
Q

Why and what about troponin bloods is important in cardiac chest pain?

A

Must repeat - 0hrs then again at three hours
Looking for a 20% rise/fall in troponin - indicates sufficient troponin elevation for STEMI/NSTEMI.

35
Q

How can previous MI be indicated on an ECG?

A

Inverted T waves.

36
Q

What is the target oxygenation saturation for patient with an acute MI?
why?

A

94-98%
Too much oxygen can make the ischemia worse.

Med 1 Block (32 decks)

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