WEEK 5 - central chest pain Flashcards
define atherosclerosis
a chronic inflammatory process triggered by the accumulation of cholesterol-containing low-density lipoprotein (LDL) particles in the arterial wall
when does coronary flow predominantly occur? why?
diastole — the coronary arteries run within the epicardial layers of the heart. the smaller branches penetrate through the muscle layers to take blood tot he deeper layers of the myocardium. therefore coronary flow occurs when the myocardium is relaxed and the smaller coronary vessels are not squeezed by contracting myocardium
how does tachycardia affect coronary blood flow?
Tachycardia increases myocardial oxygen demand (as the heart has to beat faster and hence do more work) and decreases coronary blood flow (as the duration of diastole is shortened considerably)
what are the main branches of the RCA/LCA?
RCA —> right marginal and posterior descending
LCA —> left anterior descending, left circumflex and left marginal
coronary arteries originate from the __________ ( small bulges above the aorta above the ___________)
- aortic sinuses
- aortic valve
The coronary sinus is a large venous structure located on the ________ aspect of the _____ atrium, coursing within the _____ ___________ _______. it delivers deoxygenated blood to the ____ atrium
- posterior
- left
- left atrioventricular groove
- right
what is the most likely condition from this description?
sudden onset pleuritic pain either left or right sided, with associated dyspnoea and syncope
pneumothorax
what is the most likely condition from this description?
Pain typically persistent (typically days or longer), worsened with passive and active motion and sometimes reproducible chest tenderness.
MSK
what is the most likely condition from this description?
Constant or intermittent central pleuritic sharp pain often aggravated by position (classically worse on lying down and relieved by sitting or leaning forward)
pericarditis
what is the most likely condition from this description?
Sudden onset pleuritic pain with associated dyspnoea and tachycardia. Sometimes mild fever, haemoptysis and syncope
pulmonary embolism
what are symptoms of ACS: STEMI, NSTEMI + unstable angina?
- acute, crushing pain radiating to the jaw or arm
- exertional pain relieved by rest
what are signs of ACS: STEMI, NSTEMI + unstable angina?
- sinus tachycardia
- xanthelasma
- tar staining on fingers
- a new murmur of MR (pan-systolic murmur)
what are symptoms of stable angina?
- Exertional pain/discomfort in the centre or left side of chest, throat, neck or jaw relieved by rest or GTN within a few minutes
- May radiate to neck, jaw or left arm
- Sometimes there may not be any pain but breathlessness (angina equivalent
what is examination usually like for stable angina?
Examination usually normal except indication of risk factors, e.g., xanthelasma, tar staining on fingers
what are symptoms of thoracic aortic dissection?
- sudden, tearing pain radiating to the back
- some patients have syncope, stroke, or leg ischaemia
what are 2 key signs in thoracic aortic dissection?
pulses paradoxus and difference in BP in both arms
what are 4 risk factors for thoracic aortic dissection?
- high BP
- known aortic aneurysm
- bicuspid aortic valve
- marfan’s syndrome
what are symptoms of myocarditis?
- fever
- dyspnoea
- fatigue
- chest pain (if myopericarditis)
- may be pleuritic
- recent viral or other infection
what are 2 signs of myocarditis?
- fever
- tachycardia
risk factor of myocarditis/pericarditis
recent viral illness
what is pain like in pericarditis?
constant or intermittent sharp pain often aggravated by breathing or position (classically worse on lying down and relieved by sitting or leaning forward)
what are 2 signs of pericarditis?
- tachycardia
- pericardial rub
what are signs and symptoms of a tension pneumothorax?
- significant dyspnoea
- hypotension
- neck vein distension
- tracheal deviation
- unilateral diminished breath sounds
- hyperresonance to percussion
risk factors for tension pneumothorax
- male
- genetic
- smoking
- lung disease eg. emphysema
- marfan’s syndrome
signs and symptoms of pneumonia
- pleuritic chest pain
- fever
- productive cough
- purulent sputum
- reduced air entry
- bronchial breathing
- crepitations
sign of pleurisy?
pleural rub
pain in oesophageal rupture?
- sudden and severe
- following vomiting or instrumentation
- severe epigastic pain with guarding and rigidity
pain in pancreatitis/gallstones/cholecystokinin/hepatitis?
pain in the epigastrium or lower chest that is often worse when lying flat and is relieved by leaning forward
pain in GERD?
recurrent burning pain radiating from epigastrium to throat that is exacerbated by bending down or lying down and relieved by antacids
mild epigastric tenderness
shingles: symptoms/signs/RFs
symptoms:
- sharp, band-like pain in the thorax unilaterally
- classic linear, vesicular rash
- pain may precede rash by several days
signs:
- rash on chest with vesicles
risk factors:
- immunosuppression
- older age
What changes on an ECG should be considered suspicious for coronary artery disease?
- ST segment elevation
- ST segment depression
- T wave abnormalities — hyperacute T waves are usually the first indication of an acute MI. T wave inversion can indicate ischaemia
- pathological Q waves — usually indicate current or prior MI
- LBBB
when are Q waves considered pathological?
- > 40ms (1mm) wide
- > 2mm deep
- > 25% of depth of QRS complex
- seen in leads V1-3
what are ECG characteristics of LBBB?
- broad QRS (>3 small square/0.12sec) and
- deep S wave in V1 and
- no Q wave in V5/V6
what are the 3 diagnostic features of typical anginal chest pain?
- constricting discomfort in front of chest, neck, shoulders, arms
- precipitated by physical exertion
- relieved by GTN or rest in about 5 minutes
what are the types and subtypes of coronary artery disease (CAD)?
- stable angina — no chest pain at rest
- ACS — STEMI, NSTEMI and unstable angina
(total and persist at occlusion = STEMI)
(partial or temporary occlusion = NSTEMI or unstable angina)
All patients with acute chest pain (lasting more than ___________) will need an immediate 12 lead ECG to exclude ____________. If there is no ST elevation then the patient will need to undergo __________ testing. If 6 hour troponin is elevated, it is ________, if not then it is ____________.
- 15 minutes
- ST elevation
- troponin
- NSTEMI
- unstable angina
what is normal range for troponin for both males and females?
0-14ng/L
a diagnosis of acute MI requires a ___% rise or fall in troponin within 3-6 hours after the onset of chest pain/
50%
STEMI: An additional antiplatelet (potent _______ inhibitors, e.g., __________ or prasugrel) is prescribed alongside Aspirin as recommended by the PPCI pathway guideline
- P2Y12
- ticagrelor
Dual antiplatelet therapy for people with acute STEMI having primary PCI
1.1.11: For people with acute STEMI who are having primary PCI, offer:
- _______1______, as part of dual antiplatelet therapy with aspirin, if they are not already taking an oral anticoagulant (use the maintenance dose in the ______1_______ summary of product characteristics; for people aged 75 and over, think about whether the person’s risk of bleeding with ______1_____ outweighs its effectiveness, in which case offer ticagrelor or clopidogrel as alternatives)
- _____2______, as part of dual antiplatelet therapy with aspirin, if they are already taking an oral anticoagulant.
1 = prasugrel
2 = clopidogrel
which cardiac troponins are the gold standard? what do troponins reflect?
- I and T
- reflect myocardial cellular damage
is ST depression or T wave inversion worse?
ST depression
ST elevation in what lead may imply severe left main stem or 3 vessel disease?
aVR
What is the name of the tool used in General Practice to determine somebody’s cardiovascular risk?
QRISK3 — establishes a patients 10 year risk of CV events
What components do you need to calculate the patient’s QRISK3 score?
QRISK3 requires:
- Age
- Gender
- Smoking status
- History of diabetes, hypertension
- Family history of cardiovascular event
- Physical exercise
- Diet
- BMI
- Cholesterol
QRISK3 includes more factors than QRISK2 to help enable doctors to identify those at most risk of heart disease and stroke. These are:
- Chronic kidney disease, which now includes stage 3 CKD
- Migraine
- Corticosteroids
- Systemic lupus erythematosus (SLE)
- Atypical antipsychotics
- Severe mental illness
- Erectile dysfunction
- A measure of systolic blood pressure variability
what is angina in lay terms?
angina is where you have attacks of chest pain caused by reduced blood flow to the heart. it is a symptom of CAD
NICE uses a threshold QRISK3 score of >__% for primary prevention of cardiovascular disease with lipid lowering medications
10%
what pneumonic is often used for acute STEMI management?
MONAC
- morphine
- oxygen if hypoxic
- nitrates
- aspirin
- clopidogrel
risk score in ACS? ischaemic risk and bleeding risk scores
ischaemic risk = GRACE score
bleeding risk = CRUSADE score
is aspirin an anticoagulant or anti platelet ?
antiplatelet
long term management of ACS
For secondary prevention, offer people who have had MI treatment what drugs?
- ACEi
- dual antiplatelet therapy (aspirin plus a second antiplatelet) unless they have a separate indication for anticoagulation
- beta blocker
- statin
what is aortic dissection?
Aortic dissection refers to when a break or tear forms in the inner layer of the aorta, allowing blood to flow between the layers of the wall of the aorta. There are three layers to the aorta, the intima, media and adventitia. With aortic dissection, blood enters between the intima and media layers of the aorta. A false lumen full of blood is formed within the wall of the aorta.
describe the Stanford classification for aortic dissection
- type A = ascending aorta — 2/3 cases
- type B = descending aorta, distal to left subclavian origin — 1/3 cases
describe the DeBakey classification for aortic dissection
- Type I = begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta
- Type II – isolated to the ascending aorta
- Type IIIa – begins in the descending aorta and involves only the section above the diaphragm
- Type IIIb – begins in the descending aorta and involves the aorta below the diaphragm
what are 4 conditions or procedures that affect the aorta and so increase the risk of a dissection?
- bicuspid aortic valve
- coarctation of the aorta
- aortic valve replacement
- CABG
what 2 connective tissue disorders notably increase the risk of a dissection?
Ehlers-Danlos Syndrome and Marfan’s Syndrome
what is a massive risk factor for dissection?
hypertension
what is the clinical presentation of aortic dissection?
- sudden onset of severe central chest pain that radiates through to the back and neck
- pain has a ‘ripping’ or ‘tearing’ sensation
other features:
- collapse
- hypertension
- differences in BP between arms
- radial pulse deficit (the radial pulse in one arm is decreased or absent and does not match the apex beat)
- diastolic murmur
- chest AND abdominal pain
- focal neurological deficit (eg. limb weakness or paraesthesia)
- hypotension as the dissection progresses
what are the 4 most common signs for aortic dissection?
- pulse deficits (a difference of 20mmHg or more in blood pressure between left and right arms)
- pulsus paradoxus
- muffled heart sounds
- distended neck veins
Aortic dissection is an uncommon but potentially life-threatening condition and is an acute emergency. Risk factors for dissection include ____________ which is often poorly controlled (~70% of patients), __________________ (~30%) aortopathy such as ________ aortic valve disease (~16%), connective tissues disorders and rarer hereditary conditions including _________ syndrome (~5%). A high index of suspicion is needed to diagnosis aortic dissection and if suspected, an urgent contrast thoracic __________ should be arranged. The mortality risk associated with untreated dissection is very high – up to ___% within the first 48 hours.
- hypertension
- atherosclerosis
- bicuspid
- Marfan’s
- aortogram
- 50%
Aortic dissection involving the ascending aorta is classified as Type __ (Stanford Classification) and if present an urgent cardiothoracic surgical advice should be sought for immediate surgery. For aortic dissection not involving the ascending aorta (Type __) an urgent vascular surgical referral should be made and the patient admitted for BP control and monitoring in a coronary care of high dependency unit. Lifestyle modification is recommended to reduce the risk of future dissections and include smoking cessation, BP control, diet and exercise, cholesterol and lipid control.
- A
- B
TYPE A DISSECTION IS A CARDIOTHORACIC SURGICAL EMERGENCY.
TYPE B DISSECTION IS A VASCULAR SURGICAL EMERGENCY
aortic dissection: complications of a backward tear
- aortic incompetence/regurgitation
- MI: inferior pattern is often seen due to right coronary involvement
aortic dissection: complications of a forward tear
- unequal arm pulses and BP
- stroke
- renal failure
clinical presentation of pericarditis
- sharp anterior chest pain typically relieved by leaning forward and made worse on deep inspiration or lying down
- may be associated with fever, dyspnoea, non-productive cough and flu-like symptoms
- often follows a viral illness
- pericardial rub
time course of pericarditis?
acute onset; can become subacute or chronic
what red flags do you need to consider in pericarditis?
- need to consider ACS and PE
- need to consider cardiac tamponade
look out for… high fever, subacute onset, lack response to NSAIDs after 1 week, large pericardial effusion
describe cardiac tamponade
fluid accumulates within the tough pericardial sac and restricts the filling of the heart chambers; leads to:
- reduced CO (low BP)
- raised JVP
- quiet heart sounds
diagnosis confirmed with Echo.
treatment with pericardiocentesis (drainage of the accumulated fluid in the pericardial sac)
what investigations would you do in pericarditis?
- ECG — to exclude ACS and to detec changes associated with pericarditis (widespread saddle ST elevation, followed later by T wave invesrsion)
- CRP — inflammation marker
- troponin — assess for damage to myocardium
management of pericarditis
- pain relief and anti-inflammatories (NSAIDs +/- Colchicine)
(colchicine is used for gout and familial mediterranean fever as well as present major CV events)
anterior
V1-V4 shows the anterior/septal region of the heart. this typically shows as an infarction in the LAD artery
dilation prominent in lower lobe vessels
An easy way to recall XR findings in heart failure is ABCDE.
A – alveolar oedema
B – Kerley B lines
C – cardiomegaly
D – dilation of UPPER lobe vessels
E – effusions
Upper lobe venous diversion (cephalisation) is caused by an increase in left atrial pressure (receives from pulmonary system) which can occur in pulmonary oedema.
aortic dissection
Pain can also radiate down the arms and into the neck and can be difficult to distinguish from an acute myocardial infarction. These symptoms are often associated with anterior arch or aortic root dissection. The dissection can interrupt flow to the coronary arteries, resulting in myocardial ischaemia.
The Stanford classification divides dissections into two types: A and B. Type A involves the ascending aorta but type B does not. This system also helps delineate treatment. Usually, type A dissections require surgery, whereas most type B dissections are usually best managed medically by aggressive reduction of blood pressure.
pulmonary embolism
Patients can also present with signs of hypoxia, pyrexia and later haemoptysis. Look out for risk factors such as recent surgery and immobility in this patient.
idiopathic costochondritis
Idiopathic costochondritis is also known as Tietze’s syndrome. Localized tenderness to palpation is important for diagnosis. The second rib is frequently affected in this condition.
