Ischaemic heart disease

Question 1

DDX for chest pain

Answer 1

Cardia ischaemic pain - angina
Coronary vasospasm (variant angina)- including cocaine/amphetamine use etc.
Hypertrophic cardiomyopathy
Aortic dissection, aneurysm.
Acute pericarditis
Pulmonary embolism
Myocarditis
Musculoskeletal/neuropathic pain
Oesophageal: reflux and spasm
Pneumonia/pleurisy, pneumothorax
Perforated peptic ulcer
Acute biliary disease and pancreatitis
Panic disorder/psychological
Any other?

Question 2

Causes of ischaemic heart diseas

Answer 2

90% atherosclerosis
10% other
decrease aortic diastolic pressure: AS, AR, CHF, 
Increase intraventricular pressure: MS and HTN
Increase right atrial pressure:COPD
CMP
HPTN
Shock
Servere anemmia
Lung disease

Question 3

pathogenesis of ischaemic changes to myocytes

Answer 3

coronary artery blocked = decrease O2 to mitochronia = decrease O2 to phosphorylation = decrease ATP
ATP dependent mechanisms stop
1- Sodium pump stops. = influx of calcium, sodium and thus water follows. Also efflux of K+.
results in ER swelling, cellular swelling , loss of microvilli = Blebs = loss of function
2 - Detachment of ribosome stops protein synthesis.
3 - when major ATP loss then Anaerobic glycolysis starts which decrease Glycogen stores and increase Lactic acid = decrease pH
results in Ischaemic pain.
Decrease pH = clumping of nuclear chromatin = infarction = inflammation
Stimulates inflammation

Question 4

Acute management of chest pain

Answer 4

Resus
Call for help or senior person
Attach telemetry monitoring and non-invasive monitoring
12 lead ECG to check for evolving changes
Supplement O2 via non rebreather
Gain IV access and draw bloods
Give Antiplt - Aspirin 300mg and Clopidogrel 300mg
Nitrates SL 300/600mcg Q5 mins if SBP above 90 to reduce pain and o2 requirement
Morphine 2.5 mg IV Q5 min
Alert cardiologist on call
Order CXR

Question 5

Constricting chest pain

Answer 5

angina, oesophageal spasm, anxiety

Question 6

Sharp chest pain

Answer 6

pleura or pericardium

Question 7

Prolonged (greater then 30min) of dull, central crushing pain or pressure
Radiation to shoulder, arms or neck/jaw

Answer 7

suggest MI.

Question 8

Pain precipitated by cold, exercise, palpitations or emotion

Answer 8

Cardiac or anxiety

Question 9

chest pain brought on by food, lying flat, hot drinks, or alcohol

Answer 9

oesophageal spasm