Session 9 ILOS - Chest Pain and Acute Coronary Syndromes Flashcards
Identify and differentiate between the common causes of chest pain
Different systems can because chest pain:
- Cardiac (heart and pericardial sac)
- Respiratory (lungs and pleura)
- Musculoskeletal
- GI
- Vascular
Differentiate between cardiac (visceral) and pleuritic (somatic) chest pain
Cardiac: poorly localised, dull, can be referred pain, made worse by exercise/exertion
Pleuritic: well localised, sharp, no referred pain, made worse by breathing in/coughing
Describe the risk factors for coronary atheroma (7)
Risk factors:
- Hypertension
- Hyperlipidaemia
- Advancing age
- Smoking
- Diabetes
- Sedentary lifestyle
- Gender
Describe the signs and symptoms of angina and distinguish the characteristics of unstable angina from stable angina
Angina - symptoms: (5)
- Chest pain (stable = relieves on rest within 10-15 minutes, unstable = constant pain at rest)
- Heaviness or tightness in your chest, can radiate to shoulders, arms, neck, jaw, back
- Shortness of breath
- Nausea
- Sweating
Characteristics between stable and unstable angina: (6)
- Stable relieves upon rest, unstable doesn’t
- No changes on ECG for stable generally
- Changes on ECG for unstable due to ischaemia, ST depression or T wave changes
- Pain may be more intense in Unstable
- Pain may last longer in unstable
- Risk of deteriorating further (NSTEMI/STEMI) in unstable
Describe the signs and symptoms of myocardial infarction (7)
2 types of myocardial infarction = NSTEMI or STEMI
Signs/symptoms:
- Central Crushing chest pain
- Pain can radiate from the chest to the jaw, neck, arms and back
- Shortness Of Breath
- Feeling weak/lightheaded
- Fatigue
- Looks unwell (sweaty/pallor)
- Cold sweats
Describe the signs and symptoms of acute pericarditis (7)
Signs / symptoms:
- Pain usually occurs behind the breastbone or in the left side of your chest - may spread to your left shoulder and neck
- Worse when you cough, lie down or take a deep breath / sitting up and leaning forward makes you feel better
- Cough
- Fatigue or general feeling of weakness or being sick
- Low-grade fever
- Pounding or racing heartbeat (heart palpitations)
- Shortness of breath when lying down
Describe the use of the ECG in the diagnosis of MI, distinguishing STEMI from a NSTEMI
- NSTEMI and unstable angina would show ST depression and maybe T wave changes (it could be t wave inversion or it could be normal)
- STEMI would show ST elevation
Describe the use of cardiac biomarkers as a marker for MI and to distinguish between NSTEMI & unstable angina in a patients with Acute Coronary Syndrome
- Unstable angina would not have elevated troponin
- NSTEMI and STEMI would have elevated troponin due to cardiac myocyte death
Describe the pathophysiology of stable angina, unstable angina and myocardial infarction
Stable angina:
- Partial, chronic occlusion of a coronary artery with atheromatous plaque
- Only pain on exercise, due to increased metabolic demands and insufficient blood flow
Unstable angina:
- Unstable atheromatous plaque ruptures leading to thrombus/clot formation. This clot blocks flow of blood to the rest of the heart.
- Partial occlusion
- Chest pain at rest as well as during exercise)
Myocardial infarction (NSTEMI or STEMI):
NSTEMI - greater sudden occlusion of coronary vessel
STEMI - complete sudden occlusion of coronary vessel
Understand the concept of ‘Acute Coronary Syndrome’ and explain the difference between unstable angina, NSTEMI and STEMI
Acute coronary syndromes are a spectrum of acute myocardial ischaemic events, caused by atherosclerotic plaque rupture and formation of a thrombus - causing increased occlusion in an already partially occluded coronary artery
Unstable angina - partial occlusion of a coronary artery, without necrosis
NSTEMI - myocardial infarction with ischaemia affecting partial thickness of the myocardium
STEMI - myocardial infarction with ischaemia affecting FULL thickness of the myocardium
In terms of differentiating between then, unstable angina would not have elevated troponin (NSTEMI and STEMI have elevated troponin)
Also, NSTEMI would see ST depression and maybe T wave changes (so would unstable angina), whereas STEMI would show ST elevation
Describe the principles of the management of angina, unstable angina and acute myocardial infarction
Angina:
- GTN spray (Sublingual glyceryl trinitrate) - preventative and for angina attacks
- Can give beta blockers long term (e.g. Atenolol)
Unstable angina - treatment similar to NSTEMI:
- Percutanous coronary intervention (stent)
- Antiplatlets and antithrombotics (e.g. Aspirin and Ticagrelor/Clopidogrel)
- Anti-ishcaemics (e.g. Bisopolol, GTN)
Acute myocardial infarction - STEMI:
- Give aspirin, then Ticagrelor (blood thinner), give Morphine (for pain), Nitrates
- Give oxygen if needed
- Direct transfer to catheter lab
Acute myocardial infarction - NSTEMI:
- Antiplatlets and antithrombotics (e.g. Aspirin and Ticagrelor/Clopidogrel)
- Anti-ishcaemics (e.g. Bisopolol, GTN)
- Secondary prevention (e.g. statins, ACE inhibitors)
- Consider referral to the catheter lab
Describe the investigations for myocardial infarction
2 main investigations
- Troponin blood test
- Unstable angina would not have elevated troponin
- NSTEMI and STEMI would have elevated troponin - ECG
- NSTEMI and unstable angina would show ST depression and maybe T wave changes (t wave inversion)
- STEMI would show ST elevation - Chest x-ray
Allows DR to check size of heart and blood vessels and look for fluid in lungs
Identify region of the heart affected from the particular groups of leads which show changes in myocardial infarction
LEARN THIS VERY WELL
Lateral Heart
Circumflex Artery
I, aVL, V5, V6
(Lateral leads look at the side of the left ventricle)
Inferior Heart
Right Coronary Artery
II, III, aVF
(Inferior leads look at bottom part of left ventricle)
Septal Heart
Left anterior descending artery
V1, V2
(Anterior leads look at front of heart - V1 and V2 look at right ventricle and interventricular septum)
Anterior Heart
Right Coronary artery
V3, V4
(Anterior leads look at front of heart - V3 and V4 anterior surface of ventricles)
Understand the use surgical treatments in coronary artery disease
1) Cardiac catheterisation
- Catheter guided through artery in arm or leg into coronary arteries
- Then a liquid dye is injected through catheter
- Allows doctors to identify blockages by tracing flow of dye
2) Percutaneous coronary intervention (PCI)
- Cardiac catheterisation
- Followed by catheter with small inflatable balloon at tip
- Balloon inflated, squeezing open fatty plaque deposit on inner lining of coronary artery
- Balloon inflated and catheter withdrawn
- Insertion of stent to keep coronary artery open and allow increased blood flow to heart muscle
3) Coronary artery bypass graft surgery
- Diverts blood around narrowed or clogged parts of major arteries, and provides an alternative route for blood to flow to improve blood flow and oxygen supply to heart
