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Amir Sam DPD 2018 COPY > DPD 1 - Chest pain > Flashcards

DPD 1 - Chest pain Flashcards

Chest pain: cardio & resp

1
Q

A 60 y/o man presents w/ tight, chest pain for 4 hrs. He has nausea, sweating + breathlessness. PMHx: HTN for which he takes amlodipine. What is the most likely Dx?

  1. MI
  2. Pneumonia
  3. Pericaditis
  4. Aortic dissection
  5. Costochondritis
A

MI
Breathlessness may be due to HF or arrhythmias
Nausea + sweating are associated w/ cardiac disease/ischaemia due to stimulation of vagal afferents

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2
Q

What are the Ix for chest pain? (x3)

A
  1. ECG: Is it STEMI? (If yes, aspirin/clopidogrel –> PCI (Cathlab) + Angiogram/angioplasty). Is it NSTEMI? (If yes, aspirin/clopidogrel/fondaparinux)
  2. Troponin: +ve (Coronary angiography, PCI); -ve (ETT); troponin traditionally done at 12h but can say 6h
  3. Echocardiography: identifies any regional wall motion abnormality (due to blockage of one of the coronaries/ventricular dysfunction)
    REMEMBER: ECG, Troponin, Echo
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3
Q

What are the DDx of chest pain? (x4 broad categories)

A
  1. Cardiac
  2. Respiratory
  3. GI
  4. Musculoskeletal
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4
Q

What are the cardiac causes of chest pain?

A
  1. IHD - Angina pectoris; ACS (MI) - tight chest pain w/ nausea + sweating. Rx: Diabetes, smoking, HTN
  2. Aortic dissection: sudden onset chest pain radiating to back. Rx: HTN. O/E: Difference in BP between 2 arms + early diastolic murmur (aortic regurgitation)
  3. Pericarditis: pleuritic chest pain - sharp + worse on inspiration. Better when leaning forward. Preceding flu-like illness
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5
Q

What are the respiratory causes of chest pain?

A
  1. Pulmonary Embolism: Acute onset SOB, swollen leg, pleuritic, haemoptysis. Rx: Immobility, Malignancy, FHx, recent fracture
  2. Pneumonia: Cough, Fever, Sputum
  3. Pneumothorax: Pleuritic chest pain, acute onset
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6
Q

What are the GI causes of chest pain?

A

Oesophageal spasm
Oesophagitis
Gastritis
GORD

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7
Q

What is the musculoskeletal cause of chest pain?

A

Costochondritis (Tietze’s syndrome: more localized over sternum) - musculoskeletal tenderness

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8
Q

A 60 y/o man presents w/ tight, chest pain for 4 hrs. He has nausea, sweating + breathlessness. PMHx: HTN for which he takes amlodipine. O/E: Temp 37.0, HS: S1+S2; No difference in BP in both arms; clear chest; abdo: SNT. What is the next most appropriate Ix?

  1. ECG
  2. Echo
  3. Troponin
  4. CXR
  5. CK
A

ECG

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9
Q

What coronary artery is affected in an anterior MI + which ECG leads are affected?

A

Left Anterior Descending (LAD)

V1 - V4

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10
Q

What coronary artery is affected in an inferior MI + which ECG leads are affected?

A

Right coronary artery

II, III, aVF

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11
Q

What coronary artery is affected in a lateral MI + which ECG leads are affected?

A

Left circumflex artery

V5, V6, I, aVL

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12
Q

What coronary artery is affected in a posterior MI + which ECG leads are affected?

A 
Posterior descending (usually a branch of right coronary artery)
Tall R wave + ST depression in V1 - V3
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13
Q

Which cardiac enzyme is most sensitive for MI?

A

Troponin
Measured at 3 hr & observe increments - measure serial troponin
Stays elevated for up to 2-3 days afterwards

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14
Q

A 30 y/o man comes in w/ collapse. Before: no warning. During: no tongue biting. After: Not confused. FHx: Brother died at a young age. O/E: HS: S1+S2+0; no difference in lying and standing BP, Vesicular breath sounds, Abdo SNT, CNI - XII NAD, Normal I, T, P, R, C, S, Gait. What is the most likely cause of his collapse?

  1. Aortic stenosis
  2. Pulmonary embolism
  3. Postural hypotension
  4. Seizure
  5. Tachyarrhythmia
A

Tacharrythmia e.g. VT due to FHx which indicates cardiac arrhythmia.
Not PE because there is no outflow obstruction on right side + no risk factors

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15
Q

What are the causes of collapse?

A
  1. Cardiac (VAOP): (a) Vasovagal: increase vagal discharge - bradycardia; triggers: hot weather, standing for a long time. Buzzwords: Pale, sweaty before collapse, no confusion. (b) Arrhythmia: Tachycardia, bradycardia. (c) Outflow obstruction: Left: aortic stenosis, HOCM (Thickening of septum of heart) or Right: PE (d) Postural hypotension
  2. Neurological: Seizure - aura, stereotypical movements, biting tongue, incontinence, post-ictal confusion
  3. Hypoglycaemia: DNEFG(Do not ever forget glucose), Check CBG
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16
Q

What is long QT syndrome + what are the causes of it + what does it predispose to?

A

Abnormal ventricular repolarisation
Causes: Congenital: Long QT syndrome e.g. mutations in K+ channel & FHx. Acquired: Hypokalaemia/hypomagnesia or drugs.
Predisposes to ventricular tachycardia

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17
Q

A 45 y/o man presents w/ fever + malaise. He is an IVDU. O/E: Temp: 38; raised JVP to earlobes; HS: S1 + S2 + PSM (louder on inspiration). What is the cause of his raised JVP?

  1. Constrictive pericarditis
  2. Congestive cardiac failure
  3. Aortic regurgitation
  4. Mitral regurgitation
  5. Tricuspid regurgitation
A

Tricuspid regurgitation
IVDU are prone to infective endocarditis which affects right heart and can cause tricuspid regurgitation. JVP increased to earlobes also suggests TR. PSM indicates TR or MR or ventricular septal defect however right sided murmurs are louder on inspiration (tricuspid or pulmonary) and left heart murmurs are louder on expiration (aortic or mitral)

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18
Q

What are the DDx of increased JVP? (x3)

A
  1. Right heart failure: secondary to (a) L heart failure (= CHF) or (b) pulmonary HTN (PE, COPD). In COPD, chronic hypoxia –> chronic vasoconstriction –> pulmonary HTN
  2. Tricuspid regurgitation: damage to valve leaflets (infective endocarditis/IVDU) or right ventricle dilatation of the valve ring (valve root enlarges) so leaks through valve
  3. Constrictive pericarditis: thickening/calcification of pericarditis: caused by infection (TB), inflammation (connective tissue disease e.g. Lupus, sarcoid), malignancy
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19
Q

What are the DDx of systolic murmurs?

A
  1. Aortic stenosis
  2. Mitral regurgitation
  3. Tricuspid regurgitation
  4. Ventricular septal defect
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20
Q

What are the clinical features of aortic stenosis?

A

Loudest in aortic area
Radiates to carotids
Assoc. w/ slow-rising pulse

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21
Q

What are the clinical features of mitral regurgitation?

A

Loudest in mitral area
Radiates to axilla
Assoc. w/ displaced apex beat
Loudest on expiration

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22
Q

What are the clinical features of tricuspid regurgitation?

A

Louder in tricuspid area: left lower sternal edge (assoc. w/ high JVP)
Louder on inspiration
Hepatomegaly

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23
Q

What are the clinical features of ventricular septal defect?

A

Loudest at the left sternal border accompanied by parasternal thrill

24
Q

A 65 y/o man presents with SOB, palpitations. PMHx: HTN. DHx: Bendroflumethiazide. O/E: Temp: 38; HR: 160, irregular; BP: 110/80; Dull percussion note + coarse crackles L base (consolidation). What would you expect to see on his ECG?

  1. AF
  2. Sinus tachycardia
  3. SVT
  4. VF
  5. VT
A

AF

25
Q

What does an ECG tell you? (x3)

A 
Ischaemic changes: ST elevation, depression
Electrical abnormalities: prolonged QT interval, tachycardia
Structural abnormalities (Deep S in V1, deep R in V6 = LVH =HTN)
26
Q

A 65 y/o man presents with SOB, palpitations. PMHx: HTN. DHx: Bendroflumethiazide. O/E: Temp: 38; HR: 160, irregular; BP: 110/80; Dull percussion note + coarse crackles L base (consolidation). What is the most likely diagnosis?

A

Pneumonia

27
Q

What are the characteristics + causes of sinus tachycardia?

A

Characteristics: increased HR, all components present (PQRST) P waves present
Causes: sepsis, hypovolaemia, endocrine (thyrotoxicosis, phaechromocytoma)

28
Q

What are the characteristics + causes + Tx of supraventricular tachycardia?

A

Characteristics: Fast, regular; narrow complex (< 3 small squares); no P wave before QRS
Cause: Re-entry circuit
Tx: Is pt haemodynamically stable? Yes - Vagal manouvres. No - DC cardioversion. If vagal manouvres don’t work IV adenosine 6 mg (slow conduction through AV node) –> IV adenosine 12 mg –> IV adenosine 12 mg –> IV BB, IV amiodarone

29
Q

What are the two types of SVT?

A
  1. AVNRT: Re-entry circuit at AV node (has 2 anatomical pathways). No p wave as depolarisation from AVN not SAN. Normal ECG after resolved.
  2. AVRT: Re-entry circuit via Bundle of Kent - short PR interval (P wave present) + delta wave (slurred upstroke) when not tachycardic. Tx: radiofrequency catheter ablation to destroy accessory pathway
30
Q

What are the characteristics + causes of atrial fibrillation?

A

Irregularly irregular, narrow complex tachycardia (> 120 bpm); no p waves
Causes: Thyrotoxicosis, alcohol, heart (muscle: IHD, HTN; valve (RHD); pericardium (pericarditis)), lung (pneumonia, PE, cancer, other lung pathology)
Pathogenesis: Believed that AF originates in RA near pulmonary vasculature: changes in O2, CO2 or pressure on these cells leads to AF

31
Q

What are the characteristics of atrial flutter on an ECG?

A

Chaotic atrial activity, no p waves, narrow QRS, saw-tooth baseline

32
Q

What are the characteristics + causes of ventricular tachycardia?

A

Broad complex tachycardia = VT until proven otherwise; fast, regular
Causes: ischaemia, electrolyte abnormality (K+, Mg2+), long QT (look at old ECGs)

33
Q

What is the management of acute fast AF if the patient is haemodynamically stable?

A
  1. Anticoagulation to reduce stroke
  2. Rate control w/ IV BBs, digoxin (if pt acutely unwell w/ pneumonia digoxin used less)
    If < 48 hrs onset, either DC cardioversion or flecainide (contraindicated in IHD)
    If > 48 hours, anticoagulate for 3-4 weeks before DC cardioversion (to reduce risk of cause)
34
Q

What is the management of acute fast AF if the patient is haemodynamically unstable?

A

DC cardioversion

35
Q

What is the management of pulseless VT?

A

Defibrillate

36
Q

What is the management of VT w/ no haemodynamic compromise?

A

IV amiodarone
Treat underlying cause e.g. decrease K+ or Mg2+
If recurrent, consider implantable cardiac defibrillator (ICD)

37
Q

What is the management of SVT in a pt that is haemodynamically unstable?

A

DC cardioversion - delivers shocks at specific points

38
Q

What is the management of SVT in a pt that is haemodynamically stable?

A
  1. Vagal manouvres (blow into syringe, immerse face in cold water, carotid massage)
  2. IV Adenosine (6mg then 12mg) - contraindicated in asthmatics (use verapamil instead)
  3. Cardiac strip (rhythm strip) - mark when adenosine was given
39
Q

What is the ECG finding in left ventricular hypertrophy?

A

SiR = SR
Deep S wave in V1/2 + deep R wave in V5/6 - More than 7 large squares by voltage criteria
Indicates HTN or aortic stenosis

40
Q

What are the Ix for LVH?

A

Echo (gold standard)

ECG (SiR)

41
Q

What is the characteristic ECG finding in 1st degree heart block?

A

Prolonged PR interval

May be physiologically normal in athletes

42
Q

What is the characteristic ECG finding in (a) 2nd degree heart block (b) 2nd degree Type 1 (c) 2nd degree Type 2?

A

(a) P waves not followed by QRS waves
(b) PR interval gets longer and longer until 1 failed transmission and then resets - must monitor regularly to ensure it doesn’t transition into Type 2. Usually due to functional suppression e.g. drugs, irreversible ischaemia
(c) Intermittent non-conducted P waves w/o prolongation of PR interval i.e. regularly irregular pulse. Due to structural damage e.g. infarction, necrosis, fibrosis. ‘All or nothing’ phenomenon; fixed ratio block (2:1; 3:1)

43
Q

What is the characteristic ECG finding in 3rd degree heart block?

A

Complete dissociation between P waves + QRS complexes

Broad QRS complex due to generation from ventricles (for HR, count QRS complex as this is what pumps the blood around)

44
Q

How do you treat 3rd degree heart block?

A

Acute: Atropine - blocks vagus to increase HR
Chronic: Pacemaker

45
Q

A 78 y/o man is brought in by ambulance and is unconscious and not breathing. Carotid pulse is absent + temp is 29. ECG shows irregular unformed QRS complexes with no p waves. What is the most likely diagnosis?

  1. Asystole
  2. AF
  3. VF
  4. VT
  5. SVT
A

VF

46
Q

A 78 y/o man is brought in by ambulance and is unconscious and not breathing. Carotid pulse is absent + temp is 29. ECG shows irregular unformed QRS complexes with no p waves. A diagnosis of VF is made. What is the management in this case?

A

Normally you would shock VF but in this case, hypothermia affects the metabolism of drugs (cardiotoxic) and shock will not work so only do CPR

47
Q

What is the management of VF/ Pulseless VT?

A
  1. Shock
  2. CPR (2mins)
  3. Assess rhythm
  4. Adrenaline every 3-5 mins (after 3rd shock)
  5. Amiodarone 300mg after 3 shocks
  6. Correct reversible causes (4H’s and 4Ts)
48
Q

What are the causes of VF? (x8)

A

Hypoxia, hypothermia, hypovolaemia, hypo-/hyperkalaemia

Tension pneumothorax, toxins, tamponade, thromboembolism

49
Q

What is the management of asystole/PEA?

A
  1. CPR (2 mins)
  2. Adrenaline every 3-5 mins
  3. Correct reversible causes
50
Q

A 30 y/o woman presents with URTI, pleuritc chest pain which is better when leaning forward. ECG: diffuse STEMI in all leads (global ST elevation). O/E: Temp 36.5; raised JVP; S1 + S2+ S3; Fine crackles in the chest + peripheral oedema. What is the most likely diagnosis?

A

Pericarditis
Global ST elevation (can’t have all coronaries blocked otherwise would be dead), infection + better when leaning forward all indicates pericarditis

51
Q

A 30 y/o woman presents with URTI, pleuritc chest pain which is better when leaning forward. ECG: diffuse STEMI in all leads (global ST elevation). O/E: Temp 36.5; raised JVP; S1 + S2+ S3; Fine crackles in the chest + peripheral oedema. A diagnosis of pericarditis is made. What is the Mx?

A

Analgesia + reassurance. Pericarditis is self-limiting

52
Q

What are the DDx of pleuritic chest pain?

A 
Pericarditis
Pleural pathology (sub-diaphragmatic pathology e.g. hepatic abscess)
Pneumonia
Pneumothorax
PE
53
Q

A 65 y/o woman presents w/ breathlessness over a few hours + orthopnoea. PMHx: 2 x MIs. DH: Aspirin, simvastatin, ramipril, bisprolol. O/E: S1 + S2 + S3, What is the most likely diagnosis?

A

Heart failure - SOB, orthopnoea, fine crepitations, rasied JVP, peripheral oedema + S3

54
Q

A 65 y/o woman presents w/ breathlessness over a few hours + orthopnoea. PMHx: 2 x MIs. DH: Aspirin, simvastatin, ramipril, bisprolol. O/E: S1 + S2 + S3, A diagnosis of HF is made. What is the management of acute HF?

A
  1. Sit pt up
  2. 60-100% O2
  3. GTN infusion (venodilator so decreases preload)
  4. Diamorphine (venodilator so decreases preload)
  5. IV Furosemide - not oral because if they have gut oedema with pulmonary oedema they will not absorb the drug orally. Daily weights needed.
    Treat underlying cause e.g. MI
55
Q

What is the management of chronic HF?

A

Conservative: stop smoking, alcohol and lose weight
Medical: (ABD - ACEi, BB, Diuretic e.g. spinronolactone)
1. ACEi + BB
2. ARB + spironolactone
3. Digoxin + CRT (cardiac resynchronization therapy)

Amir Sam DPD 2018 COPY (8 decks)

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