Chest Pain

Question 1

Pathologies of what anatomically could cause chest pain (8)

Answer 1

heart, aorta, lungs, pulmonary vessels, oesophagus, stomach (upper areas), thoracic nerves, or thoracic muscles.

Question 2

DDx of chest pain (17)

Answer 2

Acute coronary syndrome (MI and unstable angina)
Stable angina
Pulmonary embolism (PE)
Pleurisy (secondary to infection)
Musculoskeletal (muscle strain and infection)
Oesophagitis (secondary to gastro-oesophageal reflux disease or hiatus hernia)
Anxiety
Oesophageal spasm
Peptic ulcer disease Pneumothorax
Myopericarditis
Aortic dissection
Aortic aneurysm
Coronary spasm (e.g. secondary to cocaine) Boerhaave’s perforation of the oesophagus
Cholecystitis
Pancreatitis

Question 3

Which can cause musculoskeletal chest pain (4)

Answer 3

Cocksackie B (Bornholm’s disease)
Idiopathic costochondritis
Muscle strain
Varicella zoster infection

Question 4

What would a younger patient presenting with chest pain indicate against? (5)

Answer 4

• Acute coronary syndrome
• Stable angina
• Myopericarditis (usually post-infarction)
• Aortic dissection
• Aortic aneurysm

Question 5

What is a younger patient on the oral contraceptive pill presenting with chest pain most likely to be sugaring from? (3)

Answer 5

PE (the combined oral contraceptive pill is thrombogenic)
• Pneumothorax (especially if tall and thin)
• Cocaine-induced coronary spasm (still rare, but particularly unusual in the elderly!)

Question 6

What groups of signs should you look for in someone presenting with features of ACS

Answer 6

Hypercholesterolaemia
Systemic atherosclerotic valvular disease
Anaemia
Arrhythmias

Question 7

What should you ask about in the Hx of someone with suspected ACS

Answer 7

Smoking
Hypertension
Hypercholesterolaemia
Diabetes
FHx

Question 8

How does a pneumothorax present

Answer 8

History of sudden-onset pleuritic chest pain with breathlessness – but
beware, it may present as painless breathlessness.

Question 9

How does aortic dissection present

Answer 9

− History of sudden-onset tearing chest pain radiating to the back.

Question 10

How does ACS present

Answer 10

− History of sudden-onset, central crushing chest pain radiating to either/both arms and neck, especially in someone with a previous history of angina on exertion or MI and/or cardiovascular risk factors (smoking, hyper- tension, hypercholesterolaemia, diabetes, family history).

Question 11

What 5 diagnoses should you immediately rule out in chest pain?

Answer 11

• Acute coronary syndrome (unstable angina, or myocardial infarction (MI))
• Aortic dissection
• Pneumothorax
• PE
• Boerhaave’s perforation

Question 12

What Ix in someone suspected of MI (11)

Answer 12

ECG
Troponin
Serum cholesterol (will drop 1 day after infarct so need ASAP)
FBC
U&E's and especially K+ as it can cause arrhythmias
CRP
ESR
WCC
Cap glucose
CXR
D-dimer (not standard but to exclude PE)

Question 13

What is the Mx for ACS?

Answer 13

MONABASH
Morphine (and metaclopramide - an anti-emetic)
Oxygen
Nitrates (GTN)
Antiplatelets (aspirin, clopidogrel, glycoprotein IIb/IIIa antagonists)
Beta blockers
ACEi
Statins
Heparin

STEMI patients should also receive primary angioplasty or thrombolysis within 12 hours of onset of the pain

Question 14

What is used to assess NSTEMI patients for early angioplasty?

Answer 14

TIMI score

Question 15

Lifestyle advice for someone with IHD (4)

Answer 15

smoking cessation, low-salt diet, exercise, and weight loss.

Question 16

Risk factor control with medication for someone with IHD (4)

Answer 16

− Blood pressure control: ACE inhibitors if the patient is <55 years and
Caucasian, calcium-channel blockers or diuretic thiazides if the patient is >55 years or non-Caucasian. A mixture of these three classes of drug may be prescribed if the blood pressure cannot be controlled with one drug alone.
− Cholesterol reduction: statins, or fibrates if statins are contraindicated.
− Diabetic control: tight sugar control is important for cardiovascular risk, although far less important than blood pressure control in diabetics as
shown by the United Kingdom Prospective Diabetes Study (UKPDS) trial.
• Reduced thromboembolic risk: low-dose aspirin for life and clopidogrel for a period of 1 year.

Question 17

What is used in patients with severe left ventricular dysfunction (ejection fraction less than 30%)?

Answer 17

Implantable cardioversion devices (ICD)

Question 18

Complications of MI?

Answer 18

DARTH VADER
Death (probably not a complication to mention if asked!)
Arrhythmia
Rupture (either of the septum or the outer walls) Tamponade
Heart failure
Valve disease
Aneurysm
Dressler’s syndrome (autoimmune pericarditis 2–10 weeks after MI; note that simple post-MI pericarditis is more common than Dressler’s syndrome, pre- senting within 2–4 days)
Embolism
Re-infarction