Murtagh - Chest pain cont. in adults

Question 1

features of pain of angina pectoris

Answer 1

oppressive discomfort rather than a pain
typically transient and lasts <10 mins

Question 2

angina pectoris pain radiates to

Answer 2

mainly retrosternal and radiates to arms, jaw, throat, back

Question 3

angina pectoris associated symptoms

Answer 3

shortness of breath, faintness, sweating

Question 4

angina pectoris occurs during

Answer 4

exercise, emotion, after meals or in the cold

Question 5

angina pectoris is relieved by

Answer 5

within a few minutes with rest

Question 6

DDx of angina pectoris

Answer 6

mitral valve prolapse, oesophageal spasm, dissecting aneurysm

Question 7

causes of angina

Answer 7

coronary artery atheroma
valvular lesions (aortic stenosis)
rapid arrhythmias
anaemia

Question 8

rare causes of angina

Answer 8

vasculitis
trauma
collagen disease

Question 9

what defines stable angina

Answer 9

pain occurs with exertion and is usually predictable with no symptoms change during the past month

Question 10

what defines unstable angina

Answer 10

increasing angina (severity and duration) over a short period of time, precipitated by less effort and may come on at rest, especially at night
may eventually lead to complete infraction
it is due to unstable plaque

Question 11

angina is also called

Answer 11

crescendo angina
pre-infarct angina
acute coronary insufficiency

Question 12

nocturnal angina

Answer 12

pain occurs during the night
related to unstable angina

Question 13

decubitus angina

Answer 13

pain occurs when lying flat and is relieved by sitting up

Question 14

variant angina/prinzmetal angina/spasm angina

Answer 14

pain occurs at rest and without apparent cause
associated with typical transient ECG changes of ST elevation (as compared with classic changes of ST depression during efforts angina)
it can lead to infarction and cause arrythmias
caused by coronary artery spasm

Question 15

how might angina show up on ECG

Answer 15

may be normal
may show ischaemia or evidence of earlier infarction
during an attack it may be normal or show well-marked depression of the ST segment, symmetrical T-wave inversion or tall upright T waves

Question 16

is there a specific ECG of angina?

Answer 16

there is no specific ECG appearance typical of angina
all that can be said is that the ECG is consistent with angina

Question 17

exercise ECG

Answer 17

should be perfomed if diagnosis of coronary artery disease is in doubt
a normal stress test does not rule out coronary artery disease

Question 18

exercise thallium - 201 scan

Answer 18

helpful in some difficult circumstances such as the presence of left branch bundle block, old infarction and Wolff-parkinson-white (WPW) syndrome, when exercise test is of little use and with mitral valve prolapse (which gives false positive tests)

Question 19

how does thallium - 201 scan work

Answer 19

thallium is only taken up by perfused tissue

Question 20

gated blood pool nuclear scan

Answer 20

assesses the ejection fraction which is a reliable index of ventricular function and this aids assessment of patient for coronary artery bypass surgery

Question 21

echocardiography is used to assess

Answer 21

global and regional wall motion abnormalities and assess valvular dysfunction and pericardium status

Question 22

coronary angiography is used for

Answer 22

this test accurately outlines the extent and severity of coronary artery disease. it is usually used to determine the precise coronary artery anatomy prior to surgery

Question 23

preventions of stable angina

Answer 23

no smoking
weight reduction
healthy eating
exercise
control of hypertension
control of diabetes
control of blood lipids

Question 24

medical treatment for acute angina attack

Answer 24

nitrates (glyceryl trinitrate, isorbide trinitrate, nifedipine)
aspirin

Question 25

if angina pain persists longer than 10 minutes despite two doses of nitrates

Answer 25

take a third dose and call an ambulance

Question 26

tips for glyceryl trinitrate tablets

Answer 26

warn patient about headache and other side effects
take tablet sitting down
maximum 3 tablets in 15 minutes
tablets must be fresh
keep tablets out of light and heat
if the pain is relived quickly, spit the rest of the tablet out

Question 27

you should avoid nitrates if

Answer 27

the patient has taken sildenafil or vardenafil in the previous 24 hours of tadalafil in the previous 5 days

Question 28

to prevent angina pain in stable angina with regular predictable attacks precipitated by moderate exertion you should prescribe:

Answer 28

aspirin
beta blocker (metoprolol or atenolol)
nitrate (glyceryl trinitrate or isosorbide mononitrate)

Question 29

unstable angina includes

Answer 29

onset of angina at rest
abrupt worsening of angina
angina following acute myocardial infarction

Question 30

for variant angina (spasm)

Answer 30

use nitrates and calcium antagonist (beta blockers)

Question 31

tolerance to nitrates

Answer 31

24 hour coverage with long-acting preparations is not recommended

Question 32

the pain of myocardial infarction

Answer 32

variable, may be mistaken for indigestion
similar to angina but more oppressive
20% have no pain at all - high mortality rate

Question 33

what kind of people have painless heart attacks q

Answer 33

silent infarcts
diabetics, hypertensives, males and the elderly

Question 34

angor animi

Answer 34

fear of iminent death

Question 35

aetiology of myocardial infarction

Answer 35

thrombosis with occlusion
haemorrhage under a plaque
rupture of a plaque
coronary artery spasm

Question 36

signs of myocardial infarction

Answer 36

there may be no abnormal signs
- pale/grey, clammy, dyspnoeic
- restless and apprehensive
- variable BP with pain
- variable pulse, watch for bradyarrhythmias
- mild cardiac failure, third or forth heart sounds, basal crackles

Question 37

Q wave ECG changes

Answer 37

broad >1mm and deep >25% length of the R wave
- occurs normally in leads AVR and V1; III (sometimes)
- abnormal if in other leads
- occurs also with WPW and ventricular tachycardia (VT)
- usually permanent feature after full thickness AMI

Q waves do not develop in subendocardial infarction

Question 38

the strategies for management are based on

Answer 38

whether it is a Q wave (transmural) or non-Q wave (subendocardial) infarction

Question 39

decision whether to use thrombolytic therapy

Answer 39

Q wave infarction has to be proven to benefit from thrombolytic therapy
non-Q wave infarction does not

Question 40

T wave and ST segment ECG changes

Answer 40

transient changes (inversion and elevation respectively)

Question 41

if there is new LBBB

Answer 41

think AMI (in LBBB no Q wave)

Question 42

does a normal ECG exclude an AMI?

Answer 42

normal ECG does not exclude AMI
Q waves may take days to develop

Question 43

cardiac enzymes during myocardial infarction

Answer 43

large infarcts produce higher serum enzyme levels
these include
Troponin I or T
Creatinine Kinase

Question 44

troponin I and T

Answer 44

starts rising at 3-12 hours, peaks at 24 hours and persists for about 5-14 days
now the preferred test
positive in unstable angina

Question 45

when else might troponin be raised

Answer 45

raised in aortic dissection and kidney impairment

Question 46

is tropnonin useful for repeat MI

Answer 46

no

Question 47

creatinine kinase

Answer 47

after delay of 6-8 hours from the onset of pain it peaks at 20-24 hours and usually returns to normal by 48 hours
CK-MB: myocardial necrosis is present if >15% of total CK

Question 48

what is CK-MB

Answer 48

unlike CK, it is not affected by intramuscular injections

Question 49

technetium pyrophosphate scanning

Answer 49

it is performed from 24 hours to 14 days after onset
it scans for hot spots - especially when a postlatedral AMI is suspected and ECG is unhelpful because of pre-existing LBBB

Question 50

typical ECG features of myocardial infarction

Answer 50

Question 51

typical evolution of ECG changes with myocardial infarction

Answer 51