Week 5 - Chest Pain Flashcards
What is atherosclerosis ?
Chronic inflammatory process triggered by accumulation of cholesterol-containing, low-density lipoproteins (LDL) in the arterial wall
What is the most likely diagnosis of…
“Sudden onset pleuritic pain either left or right sided with associated dyspnoea and syncope” ??
Pneumothorax
What is the most likely diagnosis of…
“Pain typically persistent (days or longer), worsened with passive and active motion and sometimes reproducible chest tenderness” ?
Musculoskeletal pain
What is the most likely diagnosis of…
“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
What is the most likely diagnosis of…
“Constant or intermittent central pleuritic sharp pain often aggravated by position (classically worse lying down, and relieved by sitting or leaning forward)” ?
Pericarditis
What is the most likely diagnosis of…
“Sudden onset pleuritic pain with associated dyspnoea and tachycardia. Sometimes mild fever, haemoptysis and syncope” ?
Pulmonary Embolism
What is the most likely diagnosis of…
“Recurrent, vague epigastric discomfort, that is relieved by food, antacids, or both” ?
Peptic ulcer disease
List some cardiovascular conditions that would cause central chest pain …
- angina
- acute coronary syndrome
- pericarditis
- aortic dissection
List some respiratory conditions that would cause central chest pain …
- PE
- Pleurisy
- Pneumonia
List some musculoskeletal conditions that would cause central chest pain …
- rib fracture
- muscle injury
Name a skin condition that would cause central chest pain …
Shingles
List some gastrointestinal conditions that would cause central chest pain …
- peptic ulcer disease
- oesophageal spasm
- oesophageal rupture
- gall stones
What are the conditions included under the umbrella term of Acute Coronary Syndrome ?
- ST elevation MI (STEMI)
- non ST elevation MI (NSTEMI)
- unstable angina
What are the symptoms of Acute Coronary Syndrome ?
this includes: STEMI, NSTEMI, unstable angina
- acute, crushing pain
- pain radiation to jaw or arm
- exertional pain, relieved by rest
What are the signs of Acute Coronary Syndrome ?
this includes: STEMI, NSTEMI, unstable angina
- sinus tachycardia
- a new murmur (often mitral regurgitation = pan-systolic)
- Xanthelasma
- tar staining on fingers
What are the risk factors for Acute Coronary Syndrome ?
this includes: STEMI, NSTEMI, unstable angina
- hypertension
- hypercholesterolaemia
- diabetes
- cigarette smoking
- lack of physical activity
- obesity/overweight
- poor diet
What are the symptoms of stable angina ?
- exertional pain/discomfort (central/left sided in chest, throat, neck, jaw)
- relieved by rest or GTN within a few mins
- radiate to neck, jaw, left arm
- sometimes no pain, but breathlessness
What are the signs of stable angina ?
Examination usually normal except indication of risk factors e.g tar staining, xanthelasma…
What are the risk factors for stable angina ?
- hypertension
- hypercholesterolaemia
- diabetes
- cigarette smoking
- lack of physical activity
- obesity/overweight
- poor diet
What are the symptoms of thoracic aortic dissection ?
- sudden, tearing pain radiating to back
- some patients have syncope, stroke, leg ischaemia
What are the signs of thoracic aortic dissection ?
- pulses paradoxus
- different BP in both arms
What are the risk factors for a thoracic aortic dissection ?
- hypertension
- known aortic aneurysm
- bicuspid aortic valve
- Marfan’s syndrome
What are the symptoms of myocarditis ?
- fever
- dyspnoea
- fatigue
- chest pain (if myopericarditis)
- maybe pleuritic chest pain
- recent viral/other infection
What are the signs of myocarditis ?
- fever
- tachycardia
What are the risk factors for myocarditis ?
Recent viral illness
What are the symptoms of pericarditis ?
- constant or intermittent sharp chest pain
- pain often aggravated by breathing or position
- classically worse when lying down, better sitting or lent forwards
What are the signs of pericarditis ?
- tachycardia
- pericardial rub
What are the risk factors for pericarditis ?
Recent viral illness
What are the symptoms of PE ?
- sudden onset pleuritic pain, associated with tachycardia and SOB
- sometimes mild fever, haemoptysis and syncope
What are the signs of PE ?
- tachycardia
- swollen leg (unilateral, red, sore and hot)
What are the risk factors for PE ?
- immobility for long time period
- long haul flight
- inherited blood clotting disorders
- recent surgery or broken bone injury (risks are higher after both of these)
- active/history of cancer
- acute medical illness (DKA, sepsis)
- pregnancy
What are the symptoms of tension pneumothorax ?
- significant SOB
- hypotension
- raised JVP
What are the signs of tension pneumothorax ?
- tracheal deviation
- unilateral diminished breath sounds
- hyperresonance on percussion
What are the risk factors for tension pneumothorax ?
- male
- smoking
- lung disease (e.g emphysema)
- marfan’s syndrome
- genetic
What are the symptoms of pneumonia ?
- pleuritic chest pain
- fever
- productive cough
- purulent sputum
What are the signs of pneumonia ?
- bronchial breathing
- crepitations
- reduced air entry
What are the risk factors for pneumonia ?
- older age
- infective contacts
- underlying chronic lung disease
- immunosuppression
What are the symptoms of pleurisy ?
- pleuritic chest pain (exacerbated by cough)
- may have preceding pneumonia, PE or viral resp infection
What are the signs of pleurisy ?
Pleural rub
What are the risk factors for pleurisy ?
Recent infection
What are the symptoms of oesophageal rupture ?
Sudden, severe pain following vomiting or medical instrumentation (e.g imagining, feeding tubes etc)
What are the signs of oesophageal rupture ?
severe epigastric pain with guarding and rigidity
What are the risk factors for oesophageal rupture ?
- gastroscopy /imagining with throat entry
- transoesophageal echocardiography
- catheter ablation for AF
What are the symptoms of peptic ulcer disease ?
- recurrent vague epigastric discomfort
- relieved by food, antacids or both
What are the signs of peptic ulcer disease ?
epigastric discomfort
What are the risk factors for peptic ulcer disease ?
- hypertension
- hypercholesterolaemia
- diabetes
- cigarette smoking
- lack of physical activity
- obesity/overweight
- poor diet
What are the symptoms of pancreatitis ?
- epigastric pain worse when lying down, relieved leaning forward
- vomiting
- upper abdominal tenderness
What are the signs of pancreatitis ?
- epigastric pain
- jaundice
What are the shriek factors for pancreatitis ?
- high alcohol intake
- raised BMI
- female
What are the symptoms of GORD ?
- recurrent burning pain
- pain radiating from epigastrium to throat
- Exacerbated by lying/bending down
- Relieved by antacids
What are the signs of GORD ?
- mild epigastric tenderness
What are the risk factors for GORD ?
- raised BMI
- stress/anxiety
- smoking
- triggers: coffee, chocolates
What are the symptoms of MSK pain ?
- often suggested by history
- persistent pain, worsened with passive and active motion
What are the signs of MSK pain ?
Diffuse of focal tenderness
What are the risk factors for MSK pain ?
- recent injury
- heavy lifting
- osteoporosis
What are the symptoms of shingles ?
- sharp, band-like in thorax unilaterally
- classic linear, vesicular rash
- pain pain may precede rash by several days
What are the signs of shingles ?
Rash on chest with vesicles
What are the risk factors for shingles ?
- immunosuppression
- older age
What is a normal heart rate ?
Between 60-100 bpm
What are the risk factors for coronary heart disease (CHD) ?
- age
- ethnicity
- male gender
- family history
- smoking
- obesity
- exercise
- diabetes
- hyperlipidaemia
- hypertension
- inflammatory disease
Is the mortality risk following an MI higher in men or women ?
Women
due to biases and inequalities of treatment
Why are women more likely to die after an MI than men ?
inequalities and biases
- less likely to have risk factors recorded
- less likely to receive aspirin
- less likely to undergo investigation
- underepresentation in clinical trials
- women present slightly differently and it isn’t known as well as male signs of MI
What % of people survive a heart attack ?
70%
What is involved in clinical assessment for stable angina ?
- history of chest pain
- risk factors
- OBs/NEWS
- 12 lead ECG
- bloods (inc. diabetes screening)
What are the diagnostic features of typical angina chest pain ?
- constricting discomfort in chest, shoulders, neck and arms
- worse on exertion
- relieved by GTN or rest in 5 mins
Why is stable angina exertional pain ?
- atheroma narrows coronary artery/vessels
- on exertion, myocardial demand rises
- supply cannot meet demand
What is the first investigation for all patients experiencing chest pain for longer than 15 mins ?
12 lead ECG to exclude ST elevation
What is the next investigation after an ECG for patients with ongoing chest pain and no findings of ST elevation on the ECG ?
Troponin testing
After an ECG showing no ST elevation, what is indicated if the 6hr troponin test comes back…
A) elevated ?
B) not elevated ?
Elevated = NSTEMI
Not elevated = Unstable Angina
What is the immediate investigation plan for patients with acute chest pain ?
- 12 lead ECG (looking for ST elevation)
- 6hr troponin test (if no elevation found)
Which type of troponins are looked for in the 6hr troponin test ?
Troponin T
Troponin I
What happens to a patient found to have no ST elevation, but raised Troponin T or I ?
considered high risk
- admitted to coronary care unit
- undergo angiography and/or angioplasty
What tool is used to gauge a patients risk of cardiovascular events in the next 10 years ?
QRISK3 score
What information does the QRISK3 score need in order to calculate a patients risk of cardiovascular events within 10 years?
- age
- gender
- smoking status
- history of diabetes, hypertension
- family history of cardiovascular problems
- physical exercise status
- diet
- BMI
- cholesterol
As well as…
- migraine
- chronic kidney disease (inc. stage 3 CKD)
- corticosteroids
- SLE
- atypical antipsychotics
- severe mental illness
- erectile dysfunction
- systolic BP variability
What does GTN stand for?
Glyceryl trinitrate (spray)
Can a normal ECG rule out acute coronary syndrome ?
No !
NSTEMI and unstable angina can often have a normal ECG, as the pain has subsided by the time it’s performed
What test is required to rule out acute coronary syndrome in patients with chest pain but a normal ECG ?
Cardiac Troponin test
What troponin result would indicate MI ?
A 50% rise or fall in troponin within 3-6 hours after the onset of chest pain
What is the treatment for an acute STEMI ?
Dual anticoagulant therapy of aspirin paired with:
- prasugrel if not already taking oral anticoagulant (offer ticagrelor or clopidogrel as alternatives if the patient has a high risk of bleeding)
- clopidogrel if already taking an anticoagulant
Are STEMIs or NSTEMIs more common ?
NSTEMI
What treatment medications are offered to patients following an MI ?
- ACE inhibitors
- dual antiplatelet therapy (aspirin + another anticoag e.g clopidogrel)
- beta blockers
- statins
What might acute chest pain paired with breathlessness indicate ?
A respiratory cause e.g PE, Pneumothorax
What might acute chest pain paired with nausea, vomiting, pallor and sweating indicate ?
Acute MI
What might acute chest pain paired with a productive cough indicate ?
- Chest infection e.g pneumonia
- Pleurisy
What might acute chest pain paired with fever and non-specific viral symptoms indicate ?
- pericarditis
- myocarditis
What might acute chest pain paired with fever, night sweats and weight loss indicate ?
Malignancy with lung or bone metastasis causing chest pain
What might acute chest pain paired with palpitations indicate ?
Arrhythmia
What might acute chest pain paired with dizziness and syncope indicate ?
Serious acute conditions
- tachyarrythmias
- MI
- aortic dissection
- PE
- tension pneumothorax
dizziness and syncope are red flag symptoms
How is the pain described in most patients with an aortic dissection ?
- from chest, migrating to the back
- from abdomen, migrating to one or more limbs or the neck
- severe
- not affected by exertion, movement or position
What are the most common clinical signs for aortic dissection ?
- pulsus paradoxus
- distended neck veins
- muffled heart sounds
- pulse deficits (a difference of 20mmHg or more in BP between left and right arms)
What are some risk factors for aortic dissection ?
- hypertension
- atherosclerosis
- aortopathies e.g bicuspid aortic valve disease
- connective tissue disorders
- hereditary conditions e.g Marfan’s
What is the first line investigation if aortic dissection is suspected ?
Urgent contrast thoracic aortogram
What is type A aortic dissection ?
Dissection involving the ascending aorta
What is type B aortic dissection ?
Dissection not including the ascending aorta
What is the immediate treatment for type A aortic dissection ?
Surgery
What is the immediate management of type B aortic dissection ?
Admitted for urgent BP control and monitoring in a coronary high dependency care unit
