W1L4: Approach to chest pain

Question 1

Name the structures that cause chest pain (10)

Answer 1

Heart, pericardium, lungs, pleura, oesophagus, abdominal contents, aorta, chest wall, spine, skin.

Question 2

Initial investigation of a pt with chest pain?

Answer 2

ECG, cardiac enzymes (creatinine kinase and troponin), CXR

Question 3

ECG findings in AMI?

Answer 3

ST elevation: earliest change that resolves earliest +/- reciprocal ST depression
T wave invesrion after several hours
Big Q waves

Question 4

What are the cardiac causes of chest pain? (3)

Answer 4

AMI, stable/ unstable angina, pericarditis

Question 5

What are the vascular causes of chest pain? (1)

Answer 5

Aortic dissection

Question 6

What are the respiratory causes of chest pain? (4)

Answer 6

PE
Pneumonia
Pleurisy/ pleuritis
Pneumothorax

Question 7

What are the oesophageal causes of chest pain? (2)

Answer 7

Oesophagitis

Oesophageal spasm

Question 8

What are the MS and skin causes of chest pain?

Answer 8

Muscle injury/ spasm, costochondral joint inflammation, shingles

Question 9

Presentation of AMI (SQSTCRAA)

Answer 9

• Central chest pressure, tightness, squeezing, ache
• Intensity increases over a few minutes
• Radiation to shoulders, arms, neck, jaw
• Worse with exertion
• May be relieved by rest
• May be relieved by Glyceryl Tri Nitrate (GTN)
• Associated sweating, nausea, dyspnoea

Question 10

Differentiate between stable angina, unstable angina and MI:

Answer 10

Stable angina:
– Pain comes on with exercise, cold, stress
– Relieved by rest
– No recent change
Caused by atherosclerotic narrowing of coronary arteries by >70%, and occurs during exercise when myocardial oxygen demand >supply

Unstable angina:
– New onset pain or pain at rest
– Pain at lower levels of exercise

caused by:
– Ruptured atherosclerotic plaque + thrombus
– Acute narrowing or occlusion of coronary artery
– Pain due to acute decrease in myocardial oxygen supply
BUT there is no detectable release of the enzymes and biomarkers of myocardial necrosis.

AMI:
– Pain at rest

caused by:
– Ruptured atherosclerotic plaque + thrombus
– Acute narrowing or occlusion of coronary artery
– Pain due to acute decrease in myocardial oxygen supply

AND detectable release of the enzymes and biomarkers of myocardial necrosis.

Question 11

Which patients are more likely to have a painless MI?

Answer 11

Diabetics

Question 12

How is pericardial pain described (ie due to pericarditis)?

Answer 12

Site: central or LHS
Quality: sharp/ stabbing
AggF: movement, breathing

Question 13

How is pleuritic chest pain described?

Examination findings?

Answer 13

– Sharp, stabbing
– Localised
– Worse on inspiration, coughing
– May be worse on sitting up or leaning forward
– Not related to exertion

• pleural rub

Question 14

How is oesophageal chest pain described?

Answer 14

• Usually “Burning” but may be dull ache
• Worse after meals
• Worse on lying down
• Relieved by antacid
• Oesophageal spasm may be relieved by GTN

Question 15

How dissecting AA chest pain present?

Answer 15

Severe chest pain
• Radiation to the back
BP different in each arm
Early diastolic murmur of aortic regurgitation

Question 16

What is the sign of an anterior acute MI on ECG?

Answer 16

ST elevation in V1-V4

Question 17

ST depression- what is this a sign of?

Answer 17

Characteristic of myocardial ischaemia (without necrosis)