Session 9 ILOS - Chest Pain and Acute Coronary Syndromes

Question 1

Identify and differentiate between the common causes of chest pain

Answer 1

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

Question 2

Describe the risk factors for coronary atheroma

Answer 2

Risk factors: 
- Hypertension
- Hyperlipidaemia
- Gender
- Age
- Smoking
etc.

Question 3

Describe the pathophysiology of stable angina, unstable angina and myocardial infarction

Answer 3

Stable angina:

• Partial occlusion of a coronary vessel (chronic)
• Only pain on exercise, due to increased metabolic demands and insufficient blood flow

Unstable angina:

• Partial occlusion of a small coronary vessel, which ruptures to because thrombus formation and sudden increased occlusion (not complete)
• 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

Question 4

Describe the signs and symptoms of angina and distinguish the characteristics of unstable angina from stable angina

Answer 4

Angina - symptoms:

• 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
• SOB
• Nausea

Characteristics between stable and unstable angina:

• 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

Question 5

Describe the signs and symptoms of myocardial infarction

Answer 5

2 types of myocardial infarction = NSTEMI or STEMI

Signs/symptoms:

• Crushing chest pain
• Pain can radiate from the chest to the jaw, neck, arms and back
• SOB
• Feeling weak/lightheaded
• Cold sweats
• Fatigue

Question 6

Understand the concept of ‘Acute Coronary Syndrome’ and explain the difference between unstable angina, NSTEMI and STEMI

Answer 6

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

Question 7

Describe the investigations for myocardial infarction

Answer 7

2 main investigations

1. Troponin blood test
   - Unstable angina would not have elevated troponin
   - NSTEMI and STEMI would have elevated troponin
2. ECG
   - NSTEMI and unstable angina would show ST depression and maybe T wave changes
   - STEMI would show ST elevation

Question 8

Describe the use of the ECG in the diagnosis of MI, distinguishing STEMI from a NSTEMI

Answer 8

• NSTEMI and unstable angina would show ST depression and maybe T wave changes
• STEMI would show ST elevation

Question 9

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

Answer 9

• Unstable angina would not have elevated troponin

- NSTEMI and STEMI would have elevated troponin

Question 10

Describe the principles of the management of angina, unstable angina and acute myocardial infarction

Answer 10

Angina:

• Sublingual glyceryl trinitrate (GTN spray) - 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

Question 11

Describe the signs and symptoms of acute pericarditis

Answer 11

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