Week 15 - Chest pain

Question 1

where is chest pain commonly presented

Answer 1

GP
A&E

Question 2

what can chest pain be associated with

Answer 2

heart or cardiovascular system
lungs
musculoskeletal system
intestine/abdomen
nervous system

Question 3

what can cardiovascular chest pain be a sign of

Answer 3

ischaemic heart disease
pericarditis
aortic dissection
myocarditis

Question 4

what can respiratory chest pain be a sign of

Answer 4

pneumothorax
pneumonia
PE
pleurisy

Question 5

what can gastrointestinal chest pain be a sign of

Answer 5

oesophageal reflux
peptic ulcer
pancreatitis
gallstones

Question 6

what can nervous system chest pain be a sign of

Answer 6

neuropathic pain
shingles
anxiety

Question 7

what can musculoskeletal chest pain be a sign of

Answer 7

muscle strain
rib fracture
costochondritis
myositis

Question 8

respiratory symptoms

Answer 8

pleuritic
fever, productive cough
sudden onset
breathless

Question 9

GI symptoms

Answer 9

relationship to eating
epigastric pain
indigestion, heartburn
worse lying down

Question 10

MSK symptoms

Answer 10

provoking event
worse with movement
worse with breathing
tender points

Question 11

neurological symptoms

Answer 11

recurrent admissions, previous exclusion of underlying pathology
related psychiatric symptoms
follows a dermatomal pattern

Question 12

stage 0 IHD

Answer 12

no symptoms

Question 13

stage 1 IHD

Answer 13

stable angina

Question 14

stage 2 IHD

Answer 14

stable angina

Question 15

stage 3 IHD

Answer 15

unstable angina

Question 16

stage 4 IHD

Answer 16

acute myocardial infarction

Question 17

angina

Answer 17

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

Question 18

examination for angina

Answer 18

pulse
BP
heart murmurs
pallor - anaemia
peripheral pulses - neck, arms, legs, feet
BMI
signs of v high blood cholesterol

Question 19

investigations for angina

Answer 19

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

Question 20

management for angina

Answer 20

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

Question 21

symptoms and signs of acute coronary syndrome

Answer 21

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)

Question 22

investigations for acute coronary syndrome

Answer 22

12 lead ecg
- may be diagnostic with ST segment changes
- STEMI
- NSTEMI
serum highly sensitive troponin - indicates myocardial necrosis/cell death

Question 23

ECG in stemi

Answer 23

ST elevation in 2 contiguous leads

Question 24

ECG in nstemi

Answer 24

new ST depression of >0.5mm in two anatomically contiguous leads
T wave inversion in 2 anatomically contiguous leads

Question 25

management of MI

Answer 25

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

Question 26

secondary prevention of future MI/stroke/death

Answer 26

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

Question 27

secondary prevention of future MI/stroke/death

Answer 27

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

Question 28

what does the pericardium provide

Answer 28

a lubricated sac in which the heart contracts

Question 29

what is pericarditis

Answer 29

inflammation of the pericardium
may also have inflammation of heart muscle - myocarditis

Question 30

most common causes of pericarditis

Answer 30

viral infection including covid
autoimmune disease
post-MI
post cardiac surgery
pneumonia/pleurisy

Question 31

presentation of pericarditis

Answer 31

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

Question 32

aortic dissection

Answer 32

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