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Y1 Medicine (S2) - KCP > Chest Pain > Flashcards

Chest Pain Flashcards

1
Q

What are some examples of chest pain causes stemming from the cardiovascular disease?

A

Cardiovascular system
1. Ischaemic heart disease
2. Pericarditis
3. Aortic dissection
4. Myocarditis

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2
Q

What are some examples of chest pain causes stemming from the respiratory system?

A

Respiratory
1. Pneumothorax
2. Pneumonia
3. Pulmonary embolus
4. Pleurisy

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3
Q

What are some examples of chest pain causes stemming from the muscloskeletal system?

A

Musculoskeletal system
1. Muscle strain
2. Rib fracture
3. Costochondritis
4. Myositis

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4
Q

What are some examples of chest pain causes stemming from the gastrointestinal system?

A

Gastrointestinal system

  1. Oesophageal reflux
  2. Peptic ulcer
  3. Pancreatitis
  4. Gallstones
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5
Q

What are some examples of chest pain causes stemming from the nervous system?

A

Nervous system
1. Neuropathic pain
2. Shingles
3. Anxiety

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6
Q

When it comes to chest pain originating from a problem in the respiratory system, what signs should you look out for?

A
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7
Q

When it comes to chest pain originating from a problem in the gastrointesinal tract, what signs should you look out for?

A
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8
Q

When it comes to chest pain originating from a problem in the musculoskeletal system, what signs should you look out for?

A
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9
Q

When it comes to chest pain originating from a problem in the nervous system, what signs should you look out for?

A

Shingles – virus lives in the nerve endings of the spine – present in a dermatomal distribution

Chest pain can arise prior to skin rash appearing

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10
Q

What is the underlying pathology seen in ischaemic heart disease?

A

Narrowing of the blood vessels due to a build-up of fatty substance in arteries– happens over years and years

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11
Q

What are the different presentations of ischaemic heart disease?

A
  1. Stable Angina
  2. Unstable Angina
  3. Acute MI
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12
Q

What is angina? How does it present? How is the associated chest pain releived?

A

Angina - mis-match between oxygen supply and delivery in the heart

Chest tightness/pain/discomfort that occurs on excursion

Often worse in cold weather/walking into the wind

Location: central chest/radiate to throat/arm/back

Relieved by….
1. Resting
2. Sublingual glyceryl trinitrate (GTN) spray (can also be used as a diagnostic tool)

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13
Q

What investigations should be performed on someone that is suspected to have angina?

A
  1. Blood Tests
  2. 12 Lead ECG
  3. CT coronary angiography
  4. Alternatives
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14
Q

Image of CT-coronary angiography - stenosis/angina.

A
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15
Q

How are angina patients managed/treated?

A

Intensive lifestyle intervention
- Stop smoking, weight loss, exercise, diet- Mediteranean

Drug therapy
1. Sub-lingual GTN spray for symptomatic relief during an anginal episode
2. Aspirin (antiplatelet)
3. Beta-blockers (slows the heart rate, reduced myocardial O2 demands)
4. Calcium channel antagonists (coronary vasodilator)
5. Atorvastatin (reduces cholesterol)
6. Treat blood pressure-ACE inhibitor/Angiotensin receptor blocker - vasodilation and reduce fluid retnetion

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16
Q

What is acute coronary syndrome? How does it present?

A

Previously stable coronary heart disease becoming unstable - this can be either unstable angina or acute myocardial infarction

Chest Pain Presentation
1. Gradual or sudden onset
2. Tightness, pressure, crushing, band-like, weight on the chest
3. Comes at rest, minimal exertion, more intense exertion
4. Radiation to neck, jaw, arms
5. Usually lasts more than 15-20 minutes
6. No relationship with posture

Visceral pain - Nausea, vomiting, sweating, breathlessness

Risk factors - smoker, diabetes, hypertension, hypercholesterolaemia, family history of IHD/stroke/premature death of a parent

17
Q

What investigations are performed when someone is suspected of having acute coronary syndrome?

A

12 Lead ECG
- May be diagnostic - ST segment changes
- ST elevation myocardial infarction (STEMI)
- Non-ST elevation myocardial infarction (NSTEMI)

Serum highly-sensitive troponin - Indicates myocardial necrosis/cell death

18
Q

What leads are associated with infarctions in the following coronary arteries:
1. LAD - Left anterior descending coronary artery
2. LCx - left circumflex coronary artery
3. RCA – right coronary artery

A
  1. LAD - Left anterior descending coronary artery - Leads = V1-V4
  2. LCx - left circumflex coronary artery - Leads = 1, aVL, V5 and V6
  3. RCA – right coronary artery - Leads = 2, 3 and aVF

Knowing this we can localise the location of the occlusion

19
Q

What does ST elevation indicate?

A

ST elevation indicates the presence of a myocardial infarction

These ECG changes persist over time - T wave inversion and ultimately the presence of a Q wave

20
Q

Is it possible to have an non-ST elevation myocardial infarction?

A

Yes, non-ST elevation makes up the majority of heart attacks that present - ~80%

Non ST-elevation MI – depression of ST segment or Inversion of T wave wave in two anatomically contiguous leads

21
Q

How is a non-ST Elevation MI (NSTEMI) diagnosed?

A

No ST elevation, chest pain and high troponin – Non-ST elevation MI (NSTEMI)

22
Q

Difference between STEMI and NSTEMI in terms of pathology?

A

ST elevation represents – complete occlusion of a coronary artery

Non-ST elevation – caused by a block in a minor artery or a partial obstruction in a major artery.

23
Q

What do these two ECGs show? How should these patients be managed/treated?

A

STEMI – occlusion of the right coronary artery – inferior STEMI – ST elevation in leads II, III and aVF – Requires to open artery with a catheter – has to happen in 2 hours

NSTEMI – ST depression in II, III, aVF, aVL and V6 - Inferior and lateral ischemia – NSTEMI – put into hospital – get angiogram within 2-3 days – treat drugs and put a stent in to reopen

24
Q

How is acute coronary syndrome managed?

A

Management
1. Rapid diagnosis by ECG in the ambulance
2. Refer to a Specialist Cardiology service
3. Pain relief with morphine/opiate
4. Start oral aspirin and clopidogrel (Dual anti-platelet therapy)
4. Parenteral anticoagulation (IV or subcutaneous) – heparin, LMWH, factor Xa inhibitor
5. Oral or IV betablocker - reduce demand on heart

25
Q

What are 6 different things that can be done to minimise future/secondary MI/strokes?

A
  1. Aspirin/clopidogrel – anti-platelet
  2. Beta-blocker
  3. ACE inhibitor/Angiotensin receptor blocker
  4. High dose atorvastatin (regardless of baseline cholesterol) - statin
  5. Treat diabetes if present
  6. Life-style intervention – smoking cessation, diet, exercise
26
Q

What is pericarditis?

A

Pericarditis - inflammation of the pericardium (sac that contains the heart)

Occurs in younger people

None of the major risk factors but it is associated with a recent viral infection

27
Q

What is pericarditis normally associated caused by?

A

Most commonly due to:
1. Viral infection including COVID
2. Autoimmune disease
3. Post-myocardial infarction
4. Post cardiac surgery
5. Pneumonia/pleurisy

28
Q

What is pericarditis normally associated caused by?

A

Most commonly due to:
1. Viral infection including COVID
2. Autoimmune disease
3. Post-myocardial infarction
4. Post cardiac surgery
5. Pneumonia/pleurisy

29
Q

How does pericarditis normally present?

A

Younger people with no or few cardiovascular risk factors, recent viral illness (respiratory/diarrhoeal)

Presentation

Chest pain
1. Central pain
2. Relieved by leaning forward
3. May be worse with respiration i.e. pleuritic

Cardiac examination
1. Pericardial friction rub- to and fro’ rubbing sound synchronous with systole and diastole

ECG
1. Widespread ST segment elevation (concave upwards) and PR depression

30
Q

What does the ECG for pericarditis look like?

A

ECG can look like a heart attack

Widespread ST segment elevation (concave upwards) and PR depression

But…
- Widespread nature and non-classical pattern of coronary artery obstruction – indicative of pericarditis
- Also depression of the PR segment (lead II) – classic feature of pericarditis

31
Q

What is aortic dissection? What patient typically presents with it?

A

Aorta made up of three layers – intima layer breaks – allowing blood to accumulate in between layers creating a true and a false lumen

Tends to occur in people with high blood pressure (mechanical disruption) and in young patients with inherited predisposition of aortic dissection – typically Marfan’s syndrome, rarer EDS and loeys dietz and loeys dietz

32
Q

What are the common symptoms/examinations associated with aortic dissection?

A

Acute, severe chest pain
1. Pain knife-like, tearing,
2. Radiating through to the back between the shoulder blades
- Early diagnosis critical for survival

Examination
- Assymetric pulses - May lose pulses in arms or have different blood pressure between arms

Y1 Medicine (S2) - KCP (9 decks)

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