History of Chest Pain and Claudication

Question 1

Angina and claudication

-pathophysiology

Answer 1

Supply demand mismatch on exertion => ischemia

• heart ischemia => visceral pain from adenosine buildup
• leg muscle ischemia => somatic pain, can pinpoint site of stenosis

Question 2

Assessment of chest pain and claudication

Answer 2

Ensure patient is stable as you talk to them

• any pain atm?
• take quick observations (RR, HR, BP, SaO2)
• assess for acute signs

Pain

• is it stable or ACS?
• exertion vs rest pain (critical limb ischemia??)

Other symptoms

Vascular risk assessment

Question 3

Characteristics of angina

Answer 3

Constricting sensation at front of chest => neck, jaw, arms, shoulder
-lasts up to 15mins

Worse on exercise/emotional stress

Relieved by rest/GTN in less than 5mins

Question 4

Investigation for

• non angina pain
• typical/atypical pain (2+ of characteristics)

STEMI, NSTEMI found?

Answer 4

ECG done for anyone presenting to the rapid access chest pain clinic

Non angina pain - 0 or 1

• No ECG changes
• ECG ST elevation/depression, T wave inversion => CTCA

Typical (3) or atypical (2)
-CTCA

STEMI => GO TO PCI
NSTEMI => CONSIDER PCI

Question 5

Differentiating between angina and MI

Answer 5

Site/Radiation - diffuse, ant chest, left arm, neck

Onset
-angina builds up over s

Character - tight, pressure, constriction, dull

Associations - SOB, fatigue, leg ache?

Timing

• U30mins => angina
• 30mins+ => MI
• normal pattern of pain?
• episodes of prolonged pain?
• last episode?

Exacerbating, relieving

• emotional
• physical (how much exercise? does it make you stop/slow down?)
• rest/GTN
• after food? => might be more esophageal reflux pain

Question 6

Assessing pretest probability of disease

Answer 6

Past

• AMI
• CABG/PCI
• CV risk factors
• Past tests on heart

Question 7

Questions to differentiate between typical and atypical chest pain

Answer 7

If you do the same exercise on 10 different occasions, how often do you get the pain
T - 10 (v reproducible pain)
A - U10

If you have 10 pains in a row, how many happen when you are sitting quietly
T - 0/1
A - 1+

How long does the pain usually last
T - U5mins
A - 5+ mins

Question 8

Presentation of intermittent claudication

Answer 8

Stops patient on exercise
Reproducible claudication distance
Resolves quickly within 10mins
Cramp like pain
Affects calves, major active muscles
-muscles below site of blockage

Question 9

Symptom and the anatomical site of obstruction

Answer 9

Bottom, hip - aorto iliac
Thigh - aorto iliac/common iliac
Upper 2/3 of calf - superficial femoral
Lower 1/3 of calf - popliteal
Foot claudication - tibial/peroneal

Question 10

Possible other causes of leg pain

Answer 10

OA

Neuro
-nerve root compression, spinal stenosis => sciatica on bending forward

Vascular
-venous outflow obstruction => relieved by elevating leg