Week 15 - Chest pain Flashcards
where is chest pain commonly presented
GP
A&E
what can chest pain be associated with
heart or cardiovascular system
lungs
musculoskeletal system
intestine/abdomen
nervous system
what can cardiovascular chest pain be a sign of
ischaemic heart disease
pericarditis
aortic dissection
myocarditis
what can respiratory chest pain be a sign of
pneumothorax
pneumonia
PE
pleurisy
what can gastrointestinal chest pain be a sign of
oesophageal reflux
peptic ulcer
pancreatitis
gallstones
what can nervous system chest pain be a sign of
neuropathic pain
shingles
anxiety
what can musculoskeletal chest pain be a sign of
muscle strain
rib fracture
costochondritis
myositis
respiratory symptoms
pleuritic
fever, productive cough
sudden onset
breathless
GI symptoms
relationship to eating
epigastric pain
indigestion, heartburn
worse lying down
MSK symptoms
provoking event
worse with movement
worse with breathing
tender points
neurological symptoms
recurrent admissions, previous exclusion of underlying pathology
related psychiatric symptoms
follows a dermatomal pattern
stage 0 IHD
no symptoms
stage 1 IHD
stable angina
stage 2 IHD
stable angina
stage 3 IHD
unstable angina
stage 4 IHD
acute myocardial infarction
angina
a mismatch between o2 supply and delivery
exertional pain/tightness/discomfort
location - central chest, radiation to throat/arm/back
relieved by resting
relieved by sublingual glyceryl trinitrate (GTN) sublingual spray
often worse in cold weather/waling into wind
examination for angina
pulse
BP
heart murmurs
pallor - anaemia
peripheral pulses - neck, arms, legs, feet
BMI
signs of v high blood cholesterol
investigations for angina
blood tests
- full blood count to exclude anaemia
- urea and electrolytes for normal renal function
- lipids (risk factor)
- glucose, haemoglobin A1c for diabetes
12 lead ECG - often normal in someone with angina or asymptomatic ischaemic heart disease
CT coronary angiography - considered first line diagnostic test
alternatively exercise tolerance test or pharmacological stress with imaging
management for angina
intensive lifestyle intervention
- stop smoking
- weight loss
- exercise
- mediterranean diet
drug therapy
- sublingual GTN spray for symptomatic relief during angina episode
- aspirin
- beta blockers
- calcium channel antagonists (coronary vasodilator)
- atorvastatin (reduces cholesterol)
- treat BP with ACE inhibitor/angiotensin receptor blocker
symptoms and signs of acute coronary syndrome
chest pain
- gradual/sudden onset
- tightness, pressure, crushing, band like, weight on chest
- comes at rest, minimal exertion, more intense exertion
- radiation to neck, jaw, arms
- usually no more than 15-20 mins
- no relationship with posture
nausea, vomiting, sweating, SOB
cardiovascular risk - smoker, diabetes, hypertension, high cholesterol, family history (IHD, stroke, early death of parent)
investigations for acute coronary syndrome
12 lead ecg
- may be diagnostic with ST segment changes
- STEMI
- NSTEMI
serum highly sensitive troponin - indicates myocardial necrosis/cell death
ECG in stemi
ST elevation in 2 contiguous leads
ECG in nstemi
new ST depression of >0.5mm in two anatomically contiguous leads
T wave inversion in 2 anatomically contiguous leads
management of MI
rapid diagnosis by ECG in ambulance
refer to specialist cardiology service
pain relief with morphine/opiate
oral aspirin and clopidogrel (dual anti platelet therapy)
parenteral anticoagulation (iv or subcutaneous) - heparin, LMWH, factor Xa inhibitor
oral or IV beta blocker
secondary prevention of future MI/stroke/death
aspirin/clopidogrel
beta blocker
ACE inhibitor/angiotensin receptor blocker
high dose atorvastatin regardless of baseline cholesterol
treat diabetes if present
lifestyle intervention - smoking, diet, exercise
secondary prevention of future MI/stroke/death
aspirin/clopidogrel
beta blocker
ACE inhibitor/angiotensin receptor blocker
high dose atorvastatin regardless of baseline cholesterol
treat diabetes if present
lifestyle intervention - smoking, diet, exercise
what does the pericardium provide
a lubricated sac in which the heart contracts
what is pericarditis
inflammation of the pericardium
may also have inflammation of heart muscle - myocarditis
most common causes of pericarditis
viral infection including covid
autoimmune disease
post-MI
post cardiac surgery
pneumonia/pleurisy
presentation of pericarditis
younger people with no or few cardiovascular risk factors, recent viral illness
chest pain - central, relieved by leaning forward, worse on respiration
cardiac examination - pericardial friction rub
ECG - widespread ST segment elevation (concave upwards) and PR depression
aortic dissection
young patient with family history
marfan syndrome/ehlers danlos syndrome
older patient with hypertension
acute severe chest pain - knife like/tearing, radiating to back between shoulder blades
early diagnosis critical
occludes arterial branches
may lose pulse in arms/have different BP between arms
can rupture into pericardial sac and cause tamponade
