Week 5 - Central Chest Pain Flashcards
A 59-year-old male presents in A&E with a crushing chest pain that radiates to the jaw or shoulder for the past 30 minutes. He also feels short of breath and nauseous. O2 is 96% and you carry out an ECG and note that there is ST elevation in leads V3, V4. What part of the heart is likely to be affected by this MI?
anterior
V1-4 shows the anterior/septal region of the heart. this typically shows as an infarction in the LAD
what is the way to recall XR findings in heart failure
ABCDE
alveolar oedema
Kerley B lines
cardiomegaly
dilation of UPPER lobe vessels
effusions
what is not a chest x-ray finding in chronic heart failure
dilation prominent in lower lobe vessels
what is upper lobe venous diversion causes by and what is the clinical name for it
Upper lobe venous diversion (cephalisation) is caused by an increase in left atrial pressure (receives from pulmonary system) which can occur in pulmonary oedema.
A 63-year-old man with a history of high blood pressure, presents in A&E with a severe sudden-onset sharp/tearing chest pain, which radiates to the back. From the list below what is your most likely diagnosis?
aortic dissection
A 40-year-old woman develops sudden-onset dyspnoea at rest following hip replacement surgery. On examination Her airway is patent, she has a respiratory rate of 28 breaths per minute, oxygen saturation of 90%, bibasal crackles on chest sounds, pulse 132 beats per minute, Heart sounds Normal Sinus Rhythm, bilateral ankle oedema she is alert, blood sugar 6.8, temp 37.8 and abdomen soft non tender. Her electrocardiogram (ECG) shows right axis deviation.
what is the diagnosis
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.
A 23-year-old woman presents with localized left-sided chest pain that is exacerbated by coughing and is particularly painful on light pressure to that area. Pain is relieved by aspirin. The ECG is unremarkable. What is the most likely diagnosis?
idiopathic costochondritis
what is idiopathic costochondritis also known as
Tietze’s Syndrome
what is idiopathic costochondtitis
Tietze syndrome is a rare, inflammatory disorder characterized by chest pain and swelling of the cartilage of one or more of the upper ribs (costochondral junction), specifically where the ribs attach to the breastbone (sternum). Onset of pain may be gradual or sudden and may spread to affect the arms and/or shoulders. Tietze syndrome is considered a benign syndrome and, in some cases, may resolve itself without treatment. The exact cause is not known.
what is pericarditis
inflammation of the pericardium, the membrane surrounding the heart
what is the potential space between the pericardium and myocardium called
the pericardial cavity
the two layers usually touch each other, which is why it is only called a potential space
what are the potential underlying causes of the inflammation
Idiopathic (no underlying cause)
Infection (e.g., tuberculosis, HIV, coxsackievirus, Epstein–Barr virus and other viruses)
Autoimmune and inflammatory conditions (e.g., systemic lupus erythematosus and rheumatoid arthritis)
Injury to the pericardium (e.g., after myocardial infarction, open heart surgery or trauma)
Uraemia (raised urea) secondary to renal impairment
Cancer
what medications can cause pericarditis
methotraxe
what is pericardial effusion
when the potential space in the pericardial cavity fills with fluid. this creates an inward pressure on the heart, making it more difficult to expand during diastole (filling of the heart)
what is pericardial tamponade (cardiac tamponade)
where the pericardial effusion is large enough to raise the intra-pericardial pressure
this increased pressure squeezes the heart and affects it’s ability to function
what does cardiac tamponade reduce
the heart filling during diastole, decreasing the cardiac output during systole.
this is an emergency and requires prompt draining of the pericardial effusion to relieve the pressure
what are the two key presenting features for pericarditis
chest pain
low grade fever
what is the character of the chest pain
Sharp
Central/anterior
Worse with inspiration (pleuritic)
Worse on lying down
Better on sitting forward
what is a key examination finding
pericardial friction rub on auscultation
a pericardial rub is rubbing, scratching sound that occurs alongside the heart sounds
what would blood tests show in pericarditis
raised inflammatory markers (WBC;S, CRP, ESR)
what are the ECG changes seen in pericarditis
saddle-shaped ST elevation
PR depression
what can be used to diagnose a pericardial effusion
echocardiogram
what is the management of pericarditis
Non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment (e.g., aspirin or ibuprofen)
Colchicine (taken longer-term, e.g., 3 months, to reduce the risk of recurrence)
what are the two most common causes of pericarditis
viral infection and secondary to MI
what is Dressler’s syndrome
pericarditis that occurs secondary to myocardial or pericardial damage, and occurs at least 2 WEEKS after the MI
what makes Dressler;s different from normal post MI pericarditis
at least two weeks after - occurs in 7% of MI patients
what is the pathology behind Dressler’s
It is an auto-immune condition whereby the body auto-reacts against damaged myocardial tissue.
Antimyocardial antibodies are often found.
Recurrence is common
May also occur after episodes of unstable angina
Presents with massively raised ESR
where is pericarditis pain often found
retrosternal - often radiates to shoulders and neck and is aggravated by deep breathing etc
how is pericardial pain relieved
by leaning forwards
what is diagnostic for pericarditis
pericardial friction rub
usually heard in systole but may also be heard in diastole
what are the dosages of the medications used in pericarditis
Colchicine
500mcg BD for 3 months
OD if weight <70kgs
PLUS
Oral NSAID’s
- Ibuprofen 600mg TDS for two weeks, then 200-400mg TDS for 2 weeks, OR
- Aspirin 750-1000mg TDS for 2 weeks and then 250-500mg TDS for 2 weeks
- Do not use NSAID’s in the first few days after MI – as they associated with increased risk of myocardial rupture
when is chronic pericarditis said to exist
If pericarditis lasts more than 6-12 months, then chronic pericarditis is said to exist. In these cases, it is possible for the pericardium to thicken, and this can restrict ventricular filling, and then restrictive pericarditis is present
what is Ewart’s sign
this is rare
the effusion can compress the base of the left lung producing an area that is dull to percussion, just below the angle of the left scapula
what is constrictive pericarditis usually a result of and what happens to the pericardium
can be a result of TB and other infectious causes
the pericardium may become hard, fibrous and calcified.
it also occurs after open heart surgery
when do we say constrictive pericarditis is present
if it starts to interfere with ventricular filing
what is constrictive pericarditis very difficult to distinguish from and what is used to diagnose
Constrictive pericarditis is very difficult to distinguish from restrictive cardiomyopathy. The final diagnosis may depend on complex Doppler flow studies.
what is the treatment for constrictive pericarditis
complecte resection of the pericardium
this is dangerous and has a high rate of complications
what is myocarditis
inflammation of the myocardial layer of the heart muscle
what is the myocardium responsible for
it is the middle layer composed of cardiac muscle that is responsible for the heart contraction
what can the inflammation lead to
damaged myocardial cells, weakening of the heart’s pumping capacity and if severe, it can lead to acute-onset heart failure
what is acute onset heart failure secondary to myocarditis called
fulminant myocarditis
what is the epidemiology of myocarditis
All age groups can be affectedbut it commonly affects those <50
Slightly higher incidence in men than women
5% of patients with acute viral illness may have myocardial involvement
Approximately 10% of all sudden cardiac deaths in people under 35 can be attributable to myocarditis aetiology
what are the infectious causes of myocarditis
Viral (main cause);
Coxsackie viruses are the commonest culprits in Europe and North America
Other common causes:
Adenovirus
Influenza A and B
HIV
EBV
Hep B and C
Diphtheria (commonest cause globally)
There are also (less common) bacterial and fungal causes
which drugs may cause myocarditis
Cyclophosphamide, catecholamines (e.g. adrenaline, dopamine)
Amphetamines, ethanol, cocaine
Heavy metals (copper, iron, lead)
what is the typical presentation of myocarditis
can be variable - from asymptomatic all the way to life threatening heart failure
it is important to consider in a differential of chest pain, only about 1/3 of patients will present with chest pain, and over half will have fatigue
what are the symptoms of myocarditis
Fatigue
Chest pain (can be positional)
Dyspnoea/orthopnoea
Palpitations, syncope
what is sound on examination for myocarditis
S3 and S4 gallops
Pericardial rub
Tachycardia (arrythmias)
what will an ECG show for myocarditis
ST depression or elevation
T wave inversion
AV node block
what would the blood results be in myocarditis
raised troponin and CK-MB
if there is left ventricular dysfunction what treatments are given
ACEi/ARB
what is the prognosis for myocarditis
Although prognosis for many patients is good, where they have little or no residual loss of cardiac function, for some types of myocarditis (e.g. giant cell myocarditis), the prognosis can be very poor and result in death at <6 months post symptom onset.
what is stable angina a common presentation of
CDH
what is angina
myocardial ischaemia without infarct
how does angina typically present
Angina typically presents as central or left sided chest pain, with or without radiation to the neck, arm or jaw, and is generally transient, most commonly occurring on exertion, but can also be triggered by emotion
what are acute angina attacks usually treated with
nitrates
what does long term management of angina include
Long-term management involves the use of beta-blockers, calcium-channel blockers, long-acting nitrates, aspirin and statins
what is the typical presentation of stable angina
Central or left sided chest discomfort
May radiate to the jaw, arm epigastrium – like ACS pain
Can vary from mild to severe
Usually described as a “tight” or “crushing” sensation
Dyspnoea may or may not be present
Usually results from exertion
Symptoms relieved by rest
Symptoms typically of several minutes duration – shorter acting symptoms of a few seconds only are unlikely to be ischaemia related
Patient may get frequent symptoms (several times daily) or only rarely (months between episodes)
This does not necessarily correspond to the severity of the disease
what is crescendo angina
when attacks are increasing in frequency and/or severity and is correlated to high risk of severe ACS
when do you treat chest pain as ACS and not angina
if the pain doesn’t resolve within 5 minutes of cessation of active, and/or with use of GTN spray, treat as ACS
what are the typical causes of angina
atheroma
aortic valve disease
hypertrophic cardiomyopathy
what can the changes in ECG be in stable angina
pathological Q waves
ST depression
LBBB
T wave flattening or inversion
what is the usual first line investigation for stable angina and according to NICE, the primary diagnostic investigation
usually CT coronary angiogram (CTCA)
where can the pain for stable angina usually be felt
behind the sternum
what artery narrowing is associated with a poor prognosis
left main coronary artery or left anterior descending artery
what is the Canadian Cardiovascular Society Angina Classification
Class I – ‘Ordinary Activity’ (e.g. walking or climbing stairs) does not precipitate angina
Class II – Angina precipitated by walking upstairs, cold weather, or meals
Class III – marked limitation of normal physical activity
Class IV – Symptoms present at rest, unable to carry out many normal physical activities
what are the two main mechanisms used to relieve the symptoms of angina
increasing blood flow to the heart muscle by dilating the coronary arteries with GTN
decreasing the workload on the heart
what are the first line treatments to decrease the workload on the heart
beta blockers
calcium channel blockers
what are examples of beta blockers and what do they do
(e.g. atenolol or metoprolol)
Proven to reduce MI and sudden death risk
Decreases heart rate, contractility, and cardiac output – which reduces cardiac O2 demand
e.g. metoprolol 25mg BD
give examples of CCB and what do these do
Calcium channel blocker (e.g. verapamil, diltiazem)
These two agents are preferred due to their negative chronotropic events
Typically reserved for patients who are unable to tolerate beta-blockers or whose symptoms are incompletely controlled with beta-blockers
what are the second line treatments for stable angina
Long acting nitrate
e.g. isosorbide mononitritae 30mg PO OD – up to a max of 120mg daily
Typically effect lasts for 4-6 hours
Nicorandil
Ivabradine
Ranolazine
what are third line treatments
PCI
CABG
what is the investigation of choice for a child with suspected heart disease
echocardiography
