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PPS - obesity > Chest pains > Flashcards

Chest pains Flashcards

1
Q

Risk factors for MI

A

Diabetes

High blood pressure

High weight

High cholesterol/ triglycerides

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2
Q

What are the steps of investigating cause of chest pain?

A

Triage nurse determines the severity of condition

Attending A&E doctor does full work on the patient to determine the underlying cause

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3
Q

What happens to the patients in the resuscitation unit?

A

Attached to cardiac monitor - able to observe patient continuously

IV access

FBC, blood glucose, urea and electrolytes, lipids, ALT, AST and troponin

ECG - look at dynamic changes, indicating acute ischaemia.

Chest X-ray - to rule out other pathologies

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4
Q

What is an important marker for MI?

A

Troponin

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5
Q

In what other conditions are troponin levels elevated?

A

Heart failure

Renal failure

Pericarditis

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6
Q

What happens if the ECG shows ST elevation?

A

The patient would need urgent assessment by the cardiologist

Transfer to the CATH lab

For percutaneous coronary intervention

To unblock the affected artery

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7
Q

What is the treatment for suspected coronary syndrome?

A

ROMANCE

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8
Q

What does ROMANCE stand for?

A

Reassurance

Oxygen

Morphine

Aspirin

Nitrates

Clopidogrel

Emoxiprin (low molecular weight heparin)

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9
Q

What is the effect of nitrates?

A

Release nitric oxide

Induce vasodilation

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10
Q

What is the effect of clopiodogrel?

A

Antiplatelet agent used to inhibit blood clots in coronary artery disease

Inhibits purinergic P2y receptors

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11
Q

What are the steps to determine the type of chest pain the patient is experiencing?

A

SOCRATES

S - site (where?)
O - onset (is it constant, does it get better?)
C - character (is it sharp, dull or grabbing?)
R - radiation (does the pain permeate anywhere else in the body?)
A - associated symptoms (shortness of breath, palpitation, lightheadedness and syncope)
T - time (does the pain stay and go, is it constant, how long does it last?)
E - Exacerbating and alleviating (is it positional?)
S - severity (how bad is the pain from 1-10?)

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12
Q

Why is SOCRATES important?

A

Knowing these factors about the pain will allow appropriate diagnosis

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13
Q

What are possible causes of pain in the chest area?

A

Acute coronary syndrome

Pneumothorax - most important to exclude

Pulmonary embolism

Aortic dissection

Gastro-oesophageal reflux

Anxiety

Inflammation of rib joint and muscle injuries

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14
Q

What does ACS cause chest pains?

A

Causes chest pains due to significant blockage of the coronary arteries

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15
Q

Why does pneumothorax cause chest pains?

A

Air leaks in space between lung and chest wall causing them to collapse

Chest x-ray needs to be done when patient enters A&E to rule this out

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16
Q

What two tests are essential in the diagnosis of ACS?

A

ECG

Troponin levels

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17
Q

What is a STEMI?

A

ST segment elevation myocardial infarction

Most severe type of MI

Long interruption of the heart’s blood supply

Extensive damage to a large area of the myocardium

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18
Q

What is a NSTEMI?

A

Non-ST segment elevation myocardial infarction

An NSTEMI results from a partial interruption of blood supply to the heart

Smaller region of damage to the myocardium compared to STEMI

ST depression or T wave inversion

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19
Q

What is an unstable angina?

A

Least serious form of ACS

Still a medical emergency

Blood supply is seriously restricted

There is no permanent damage to the myocardium

Negative troponin levels but may have some changes to the ECG

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20
Q

What are the three types of ACS?

A

STEMI

NSTEMI

Unstable angina

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21
Q

What are the two main diagnostic tests for acute MI?

A

12-lead ECG

Troponin

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22
Q

When should the ECG performed?

A

Within 10 minutes of being admitted to hospital with chest pains

Provides key information to help confirm what level and type of damage has been inflected upon the myocardium

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23
Q

What is troponin used for?

A

Primary test to look for myocyte damage/ death

To confirm diagnosis

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24
Q

When should troponin be measured?

A

High sensitivity troponin test can detect raised troponin 3 hours after onset of chest pain

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25
Q

Where are the leads in a 12-limb ECG placed?

A

6 on the chest

One on each limb

26
Q

How many leads make up the 12-lead ECG?

A

10

Obtain 12 electrical views of the heart

27
Q

Why is it important to place the leads correctly?

A

Angles at which the electrodes look at the heart and the direction of the heart’s electrical depolarisation

Important to place leads accurately so the tracing is accurate

28
Q

Which are the limb leads?

A

aVR

aVL

aVF

29
Q

Which are the chest leads?

A

V1-V6

30
Q

What does lead II indicate?

A

Rhythm strip

Shows trends in heart rate and basic rhythm

31
Q

Why is it important to understand which lead corresponds to which position?

A

In order to localise the pathology to a particular heart region

32
Q

What does ST elevation in V3 and V4 indicate?

A

Anterior MI

33
Q

What does ST elevation in V2, V3 and aVF indicate?

A

Inferior MI

34
Q

What does ST elevation in V1, aVL, V5 and V6 indicate?

A

Lateral MI

35
Q

What does ST elevation in V1 and V2 indicate?

A

Septal MI

36
Q

Anterior MI

A

ST elevation in V3 and V4

37
Q

Inferior MI

A

ST elevation in V2, V3 and aVF

38
Q

Lateral MI

A

ST elevation in V1, aVL, V5 and V6

39
Q

Septal MI

A

ST elevation in V1 and V2

40
Q

What does the P wave indicate?

A

Atrial depolarisation

41
Q

What does the QRS complex indicate?

A

Ventricular depolarisation

42
Q

What does the PR interval indicate?

A

Time interval between the first deflection of the P wave and the first deflection of the QRS complex

Transit time for the electrical signal to travel from the SAN to the ventricles

43
Q

What does the T wave represent?

A

Ventricular repolarisation

44
Q

What does the ST segment represent?

A

Period of zero potential between ventricular depolarisation and repolarisation

Provides information about the blood supply to the heart

If elevated = blood supply is significantly compromised

45
Q

When is ST elevation significant?

A

When there is more that 1 mm elevation from the baseline in at least 2 adjacent limb leads

Or more than 2 mm of elevation in 2 adjacent chest leads

Or a new onset left bundle branch block

46
Q

What are characteristics of the ECG in NSTEMI?

A

Lack specificity

Must be interpreted within the context of the clinical scenario

Pathological Q wave - indicate MI has happened at some point

47
Q

Characteristics of pathological Q waves

A

Downward deflection wider than 2 small squares or greater in height than 1/3 of the subsequent T wave

48
Q

How long do pathological Q waves take to develop?

A

Takes hours to develop

49
Q

How long do pathological Q waves last?

A

Rarely goes away once developed

50
Q

Absence of pathological Q wave means that MI has not happened

TRUE or FALSE

A

FALSE

Absence of pathological Q wave does not eliminate the diagnosis of MI

51
Q

What happens if MI is suspected in patient?

A

MI is medical emergency

When suspected in patient, initial treatment will begin before some tests are carried out to confirm diagnosis

52
Q

What are tests used for diagnosis and monitoring?

A

Troponin

FBC

Arterial blood gases

Renal function

Blood glucose

53
Q

Why is a FBC ordered in MI patients?

A

Anaemia may precipitate an MI in angina patients

54
Q

Why are arterial blood gases measured in MI patients?

A

Determine levels of

  • hypoxia
  • pH
  • lactate
  • glucose
  • haemoglobin
55
Q

Why are renal function tests ordered in MI patients?

A

Urea and electrolytes may be dysregulated or worsen due to poor renal perfusion in cardiogenic shock

Hypokalaemia may predispose to arrhythmias

56
Q

Why is blood glucose measured in MI patients?

A

Diabetes must be controlled aggressively after an MI

With intravenous insulin infusions

57
Q

What happens after diagnosis of MI?

A

Admission to cardiac care units

Treatments given

58
Q

What causes ST elevation?

A

Total occlusion of the coronary circulation supplying an area of the heart causes necrosis of the whole wall of the heart

This causes the area to depolarise as the ion movements cannot be controlled

Electrodes measure the movement of electricity through the heart

Depolarisation of the necrosed area travels to the neighbouring areas of the heart

This is picked up by the electrodes and causes a negative deflection of the baseline of the ECG rather than a true baseline

When positive vector travels away from the electrode it is represented as a negative deflection on the ECG

During ST it is back to true baseline - but this is perceived as elevated as initially the potential is affected by the necrosed area

59
Q

Differences in affected areas of the heart in STEMI and NSTEMI

A

STEMI - transmural infarct

NSTEMI - subendocardial infarct as most distal to coronary arteries

60
Q

How can we differentiate NSTEMI from unstable angina?

A

Cardiac markers

Troponin is positive in NSTEMI due to infarct but negative in unstable angina due to ischaemia

61
Q

What is the reason behind the positive deflection in NSTEMI?

A

NSTEMI is also characterised by infarct area

This is depolarised

This time the positive vector is travelling towards the electrode

This results in positive deflection in the ECG

Causes an abnormal positive baseline compared to true baseline

So the ST segment reflecting a voltage of 0 appears depressed

62
Q

Why are ST changes acute?

A

ST changes are acute and disappear over time

Infarct tissue

Fibrosis does not have ionic leakage as in infarct tissue

So there is no baseline shift

PPS - obesity (6 decks)

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