S9 Chest Pain and Acute Coronary Syndromes Flashcards
How do you diagnose what a chest pain is due to?
- take a history
- do a clinical examination e.g. auscultation of chest
- carry out investigations e.g. ECG and blood tests
What factors do you consider when taking a history?
Site Quality Intensity Timing Aggravating factors Relieving factors Secondary symptoms
SQUITARS
What respiratory problems can cause chest pain?
- pneumonia - irritates the parietal pleura
* pulmonary embolism - irritates the parietal pleura
What cardiac problems can cause chest pain?
- MI
- stable/unstable angina
- pericarditis - non-ischaemic chest pain
What MSK problems can cause chest pain?
- broken rib
* costochondritis - inflammation of costal cartilages
What GI problems can cause chest pain?
- oesophagus - reflux
You can get pleuritic chest pain, which is related to pain in the pleura but also pleuritic chest pain that has similar pain but in different areas, what problems can cause this type of pain?
- pneumonia
- pulmonary embolism
- pericarditis
- broken rib
- costochondritis
What is cardiac (visceral) pain like?
- dull
- poorly localised
- worsened with exertion
- may radiate to shoulder/jaw
What is pleuritic (somatic) pain like?
- sharp
- well localised
- worse with inspiration/coughing/positional movement
What is pericarditis?
Inflammation of the pericardium
Who is pericarditis more common in?
Men and adults
What is the common cause of pericarditis?
Viral
Can also be bacterial e.g. TB, cancer or autoimmune
How does pericarditis present?
- retrosternal (behind sternum) chest pain
- sharp
- localised to front of chest
- aggravated with inspiration, cough, lying flat
- eased with sitting up and leaning forward
- pericardial rub may be heard on auscultation
What does the ECG look like for someone with pericarditis?
Widespread saddle-shaped ST segment elevation
What is cardiac, ischaemic chest pain due to?
Secondary to pathology involving the heart e.g. ischaemic heart disease
What is the pathophysiology of ischaemic heart disease?
Atherosclerosis - a build up over time of lipid within the tunica intima/media with a fibrous external cap
What are the modifiable risk factors for atherosclerosis and so ischaemic heart disease?
- smoking
- hypertension
- dyslipidaemia
- diabetes
- obesity
- sedentary lifestyle
What are the non-modifiable risk factors for atherosclerosis and so ischaemic heart disease?
- advanced age
- family history of ischaemic heart disease
- male sex
What is stable angina?
Ischaemia only occurs when metabolic demands of cardiac muscle are greater than what can be delivered via the coronary arteries e.g. when doing exercise
The atherosclerotic plaque is stable
What conditions are involved in acute coronary syndrome?
- unstable angina
- MI - STEMI and NSTEMI
(Stable angina is chronic)
What causes acute coronary syndromes?
Caused by atherosclerotic coronary artery disease
- atheromatous plaque ruptures with thrombus formation
- acute increased occlusion in an already partially occluded lumen * leads to ischaemia and potentially infarction
When are cardiac enzymes leaked?
When cardiac muscle cell necrosis occurs - infarction - NSTEMI and STEMI
What is the typical patient history for someone with unstable angina?
- pain occurs at rest as well as with exertion
- more intense pain than with stable
- pain may last longer than with stable
What are the ECG changes and blood test - troponin results for someone with unstable angina?
- ST depression, T wave inversion (could be normal)
* negative
What is the typical patient history for someone with myocardial infarction?
- present similar to someone wit unstable angina
- may have pain that spreads to shoulder and jaw
Autonomic features: - nausea
- sweating
- pallor
What are the ECG changes and blood test - troponin results for someone with myocardial infarction, STEMI and NSTEMI?
STEMI - ST elevation and troponin positive
NSTEMI - ST depression, T wave inversion and troponin positive
In STEMI what does ECG leads affected help determine?
Anatomical location of the ischaemia/infarct
Where is ST elevation seen in an inferior STEMI?
ST elevation in leads II, III and aVF
