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Cardiovascular system > Lecture 16- Chest pain > Flashcards

Lecture 16- Chest pain Flashcards

1
Q

Chest pain is a common presenting complaint it can be

A

life-threatening to non-urgent.

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2
Q

diagnosis is based on

A
  1. History (most important)
    • Reach differential diagnosis
  2. Clinical examination
    • Compliments history
  3. Investigations
    • Full blood count- infection
    • Troponin I/T- cardiac event
    • Informed by history and clinical exam
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3
Q

History taken

A

Site: location of the pain and if it radiates

Quality: How the pain feels (e..g sharp or dull)

Intensity: effect on patient, severity score

Timing: when it started, sudden or gradual onset

Aggravating factors: What makes a pain worse

Relieving factors: what makes pain better

Secondary symptoms: Other symptoms

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4
Q

causes of chest pain

A

respiratory

cardiac

GI

MSK

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5
Q

respiratory causes of chest pain

A
  • Pneumonia
  • Pulmonary embolism
  • Pneumothorax
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6
Q

If it starts to involve the pleura

A

–> Pleuritic pain

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7
Q

Pleuritic pain

A
  • Sharp
  • Well localised (pt can point at pain)
  • Worsens with inspiration, coughing and positional movement (lying on back)
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8
Q

cardiac causes of chest pain

A
  • MI
  • Pericarditis- pleuritic pain
  • Stable angina
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9
Q

Gastrointestinal

A

Gastro-oesophageal reflex – burning pain in the middle

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10
Q

Musculoskeletal (MSK)

A
  • Broken rib
  • Costochondritis
  • Inflammation of the costal cartilage
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11
Q

Chest pain: Cardiac vs Pleuritic

A
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12
Q

Cardiac (ischaemic) pain

A
  • Heart muscle
  • Dull/crushing pain
  • Poorly localised (cant point to)
  • Worsened by exercise
  • May radiate to shoulder and joint
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13
Q

Pleuritic pain

A
  • Sharp
  • Often well localised
  • Worsens with inspiration, coughing, positional movement

*pericarditis and MSK disorders can make pleuritic pain*

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14
Q
A
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15
Q

cardiac causes of chest pain

A
  • Non-ischaemic e.g. pericarditis
  • Ischaemic and infarction (diseases relating to coronary arteries)
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16
Q

Cardiac (ischaemic pain)

A
  • Pain secondary to pathology involving the heart
    • Ischaemic heart disease
  • Potentially life threating
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17
Q

Pathophysiology of IHD- Atherosclerosis

A
  • Builds up over time –> lipid laden cap with fibrous external cap (brittle)
  • Cap ruptures –> occlusion of the artery
  • Distal tissue not supplied with enough oxygen
18
Q

Risk factors for IHD

A
  • Modifiable
    • Smoking
    • Hypertension
    • Dyslipidaemia
    • Diabetes
    • Obesity
    • Sedentary lifestyle
  • Non modifiable
    • Advanced age
    • Family history (of early IHD)
    • Male sex
19
Q

Stable angina

A

Caused by a stable occlusion. Tissue will only become ischaemic when exercising (metabolic demand increases) –> cannot keep up with oxygen demand.

20
Q

Typical patient history of someone with stable angina

A
  • Cardiac sounding chest pain (dull)
  • Use of GTN spray to alleviate symptoms
  • Relief at rest
  • Exacerbated with exercise
21
Q

Pericarditis

A

Inflammation of the pericardium

22
Q

pericarditis more common in

A

male adults

23
Q

cause of pericarditis

A

typically viral

24
Q

pericarditis symptoms

A
  • Presents with retrosternal chest pain
    • Sharp, localised to front of chest
    • Aggravated with inspiration, cough, lying flat
    • Eased with sitting up and leaning forward
    • Pericardial rub may be heard on auscultation
      • ​**Pericardial rub heard with stethoscope
25
Q

Acute coronary syndrome

A

Caused by myocardial ischaemia caused by atherosclerotic coronary artery disease.

26
Q

outline aetiology of ACS

A
  1. Acute deterioration of plaque
  2. Platelet aggregation
  3. Formation of thrombus
  4. Partially occlusive thrombus
  5. Acute occlusion due to thrombus
  6. Ischaemia and potential infarction (myocardial tissue necrosis)
27
Q

types of acute coronary syndrome

A

A Stable angina (not ACS)

B Unstable angina

C Non-ST elevation myocardial infarction (NSTEMI)

D ST elevation myocardial infarction (STEMI)

E Myocardial infarction

28
Q

unstable angina vs MI (NSTEMI and STEMI)

A

unstable angina- heart tissue ischaemia–> no cardiac enzyme leak

MI- heart tissue death (infarction) –> cardiac enzyme leak from necroses cardiac muscle cells

29
Q

Stable angina is not

A

an acute coronary syndrome

30
Q

Features of a myocardial infraction

A
  • Chest pain at rest
  • Severe dull pain
  • GTN spray doesn’t work
  • Autonomic features
    • Sweating
    • Nauseous
    • Pallor
  • Radiate to jaw and arm
31
Q

STEMI

A
  • Complete thrombus occlusion
  • Ischaemia and necrosis of myocardiocytes
  • More severe symptoms
    *
32
Q

ECG in STEMI

A
  • ST elevation (may be widespread or limited to region of the heart e.g. the anteroseptal- LAD)
  • Hyperacute T waves
33
Q

STEMI Blood tests

A

- elevated troponin T/I

34
Q

NSTEMI

A

Occluding thrombus sufficient to cause tissue damage and mild myocardial necrosis

35
Q

ECG in NSTEMI

A
  • ST depression
  • T wave inversion or flattening on
36
Q

NSTEMI blood test

A

Blood test- elevated cardiac enzyme

37
Q

*How to differentiate between UA and NSTEMI?

A
  • Troponin I/T
  • No tissue death yet
38
Q
A
39
Q

in stable angina pts are ….. at rest

A

pain free

40
Q

with unstable angina, NSTEMI, STEMI pts are ….. at rest

A

in pain

41
Q

Case study 1

A 55 year old man presents with chest pain. He describes it as sharp, and indicates with his fingers to an area to the left of the sternum, which is very tender to palpation. The pain is worse when he breathes deeply or coughs. He doesn’t report pain being felt anywhere else and feels otherwise well but is anxious about the pain. He’s had it for a few days. He has a history of hypertension and is a current smoker.

What is the most likely diagnosis?

A

Not retrosternal–> does not radiate

  • Pericarditis
    • Inflammation of pericardial sac
    • Eases when sitting forward
    • Unusual to have point tenderness
  • or costochondritis
    • Sharp
    • Localised
42
Q

Case study 2

A 65 year old man presents with chest pain. He describes it as dull and heavy in the centre of his chest, but he feels an ache in his shoulder too. It started quite rapidly, nearly an hour ago while he was sat down. He feels nauseous and sweaty. He has a history of hypertension and is a current smoker. What is the most likely diagnosis?

A

MI

  • Angina can also radiate though
  • Look at troponin

Cardiovascular system (30 decks)

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