Chest pain workshop Flashcards
What are the differential causes of non-cardiac chest pain?
Trauma
Malignancy
FORD
MSK - costochondritis
Pleurisy
Pneumothorax
PE
What is meant by cardiac chest pain?
Severe central/left sided crushing pain in chest
May radiate to the left shoulder/jaw
May be accompanied with SOB, nausea or lightheadedness
What are the common differentials of cardiac chest pain?
Vascular - thoracic aortic aneurysm, thoracic aortic dissection
Valvular - aortic stenosis
Pericardial - pericarditis, myocarditis
Cardiac - stable angina, acute coronary syndrome
Describe the process of atherosclerosis formation
- Endothelial damage and immune response - wbc migrate to site, accumulate and cause inflammation
- Fatty streak formation - macrophages phagocytose cholesterol to form foam cells, dead foam cells gather, inflammation cycle
- Plaque growth - fibrous cap grows over plaque, growing plaque narrows the lumen
- Plaque rupture or erosion - blood clot forms due to rupture or erosion, stops blood flow = MI or stroke.
What are some non-modifiable risk factors for atherosclerosis?
Increasing age
Family history of CVD (MI in first degree relatives M<55 F<65)
Gender - male
Ethnicity - African carribean
What are the medical risk factors for atherosclerosis?
Diabetes (hyperglycemia and dyslipidaemia)
Hypertension
Dyslipidaemia - High LDL low HDL
Metabolic syndrome
What are the key life-style risk factors for atherosclerosis?
Smoking or tobacco use
High saturated fat diet
Lack of physical activity
What are some key complications of atherosclerosis?
Ischaemic heart disease
ACS
Mesenteric ischaemia
Peripheral artery disease
Renal artery stenosis
Stroke
TIA
What is the key difference in a history between stable and unstable angina?
Unstable - brough on at rest e.g lying down, eating - not predictable Stable - predictable, after a certain level of exertion.
What are the triad of clinical factors that indicate stable angina?
Cardiac sounding chest pain
Brough on by exertion - often reproducible and predictable
Relieved by rest/GTN spray.
What bedside investigations may be done for a patient with stable angina as a differential?
Obs - (BP in both arms - rule out aortic dissection)
ECG - ST elevation/depression
SCORE - QRISK2
What is the purpose of a QRISK2 score in stable angina?
Is risk >10% mortality of CVD within next ten years start on statin.
What are some key factors considered within the QRISK3 score?
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
According to QRISK3 which modifiable factor has the greatest affect on a persons risk of cardiovascular disease morality?
Smoking
What bloods should be taken in a patient with stable angina as a differential diagnosis?
FBC
U+Es
Lipids
HbA1c / random glucose
Troponin
What imaging should be ordered for a patient with stable angina as a differential diagnosis?**
Elective CT angiogram (extent of damage)
What conservative management should be offered to patients with stable angina?
Lifestyle changes - smoking cessation, weight loss, increase exercise, improve diet.
What medical management should be offered to patients with stable angina?
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
What surgical management should be offered to patients with stable angina?
Recanalization - angioplasty (drug coated balloon/drug eluting stent - useful in single vessel disease
Coronary artery bypass grafting (CABG) - multiple vessel disease or complete occlusion.
What is the basic physiology underpinning angina?
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.
How does acute coronary syndrome present?
Cardiac sounding chest pain (may radiate to L arm/jaw + unpredictable (occurs at rest) does not respond well to GTN spray
What are the three subcategories of conditions within acute coronary syndrome?
How to differentiate between them?
Unstable angina - no ST elevation, no trop rise
NSTEM - trop rise, no ST elevation
STEMI - widespread ST elevation and trop rise.
What is the key difference between a STEMI and an NSTEMI?
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.
What is the key way to recognise a STEMI on an ECG?
Tomb stone appearance
What are the key signs of pericarditis on an ECG?
Saddle shaped ST elevations throughout the ECG
Typically, no inverted T waves, no presence of Q waves.
What is the management of acute MI?
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.
What is meant by percutaneous intervention?
Invasive procedures to increase blood supply to the heart by dilating the blood vessels
Includes coronary angioplasty/stenting.
What scoring systems is used to determine the management plan of NSTEMI/UA?
GRACE score
What is the conservative management for sub-acute/chronic acute coronary syndrome?
Telemetry monitoring - high risk of cardiac arrest in sub-acute period
Smoking cessation
Cardiac rehab
What is the medical management of sub-acute/chronic MI?
Clopidogrel
Ramipril
Aspirin 75mg
Beta blocker
Statin
CRABS
Aspirin discontinued after 12 months
What ECG rhythms indicate a cardiac arrest?
Ventricular Tachycadria
Ventricular fibrillation
Pulseless electrical activity
Asystole
What cardiac arrest rhythms are shockable?
Ventricular fibrillation
ventricular tachycardia.
How do differentiate between MSK pain and cardiac pain on physical examination>
Press on the chest, between the ribs - this will exacerbate MSK pain, will not effect cardiac pain.
Why and what about troponin bloods is important in cardiac chest pain?
Must repeat - 0hrs then again at three hours
Looking for a 20% rise/fall in troponin - indicates sufficient troponin elevation for STEMI/NSTEMI.
How can previous MI be indicated on an ECG?
Inverted T waves.
What is the target oxygenation saturation for patient with an acute MI?
why?
94-98%
Too much oxygen can make the ischemia worse.
