Acute Central Chest Pain Flashcards

Question

Examination signs: Viral pleuritis

Answer 1

* Pleural friction rub w or without low grade dever

Answer 2

* Reproducible pain on chest wall palpation especially at costochondral junctions (junction between costal cartilage and rib bone)

Answer 3

Tenderness unilaterally in a dermatomal distribution - with or without typical rash indicates herpes zoster (pain presents 2-3 days prior to rash) Rash is vesicular on an erythematous base in unilateral distribution of one dermatome.

Answer 4

* Temperature, blood pressure, pulse, respiratory rate * Heart rhthym * oxygen saturation pulse oximetry * Resting 12 lead ECG * Make sure pain is controlled - any exacerabtions should be taken into account.

Answer 5

* **Resting ECG** - often normal in stable angina, but ST depressions may indicate ischaemia or Q waves indicative of prior infarction * **FBC** - anaemia leads to additional cardiac workload and reduced O2 delivery to myocardiu, which exacerbates angina * **Fasting lipid profile** - hyerplipidaemia associated with Ischaemic heart disease - elevated LDL = higher risk, elevated HDL = protective * **HbA1c or fasting blood glucose** - hyperglycaemia linked to ischaemic heart disease

Answer 6

* TSH - hyperthyroidism increased metabolic demand and cardiac workload - can exacerbate angina. Hypothyroidism is associated with dyslipidaemia and ischaemic heart disease * Stress exercise ECG - ECG before, during and after exercise, assess exercise capacity and heart rate achieved, haemodynamic response to exercise. - Looking for ST segement elevation and depression to identify ischemia. * Imaging - stress plus CT/ echocardiogram/ cardiac magnetic resonance or stress positron emission tomography (PET). Imaging modality depends on patient demographic and qu. - To help identify wall motion or perfusion abnormalities * CCTA - Cardiac computed tomographic angiography - British guideline recommended. Looking for luminal narrowing - \> 50% considered positive or identification of plaques. * Invasive coronary angiography - 50-70% luminal narrowing is considered coronary obstruction. Invasive coronary angiography not typically used for initial diagnosis but may be used to confirm, risk stratify, identify if appropriate for revascularisation.

Answer 7

* **ECG** * ST elevation MI (STEMI) - ST elevation \> 1mm in 2 anatomically adjacent leads or new left bundle branch block * NSTEMI or unstable angina --\> ST segment depression or T wave inversion * **Trial sublingual glyceryl trinitrate - also control pain** * **CXR** * normal or signs of heart failure e.g. increased alveolar markings * blood diversion to upper lobes * cardiomegaly * pleural effusion * kerley B lines (septal lines) - interlobular septa become prominent due to oedema in the connective tissue inbetween lung lobes. Kerley B - often 1 - 2 cm in periphery of lung, extend out to pleural lining. * **Cardiac Enzymes (troponin and creatinine kinase MB)** * ****elevated in STEMI and NSTEMI * Troponin released into blood 3-4 hours after MI, peaks 24 hrs, remains detectable for 10- 14 days * Troponin more specific but less useful to detect reinfarction * Creatinine kinase - rises 3/4 hrs after MI, remains elevated 3-4 days- useful to detect reinfarction * FBC -\> thrombocytopenia to estimate risk of bleeding * U and E's --\> Urea and creatinine to monitor kidney function, electrolytes to monitor risk of cardiac arrhythmia * LFT --\> useful if considering tx with drugs that undergo hepatic metabolism * **Other investigations:** * **B type natriuretic peptide (BNP and NT-proBNP)** - released during ischaemia, helps to risk stratify. * **Coronary angiography** - STEMI - critical occlusion of coronary artery, NSTEMI and unstable angina - evidence of coronary artery narrowing. STEMI- urgent coronary angiography with reperfusion. NSTEMI/UnstableA - if high risk features (ongoing chest pain, ECG changes, elevated cardiac enzymes).

Answer 8

* ECG - upwards concave ST segment elevation with PR depressions (60% patients). * Serum troponin - if raised suggests myocardial involvement and coincides with magnitude of ST segment elevation. Usually midly elevated, can be in range of acute MI. * pericardial fluid/ blood culture --\> purulent pericarditis is lifethreatening requires immediate confirmation via urgent pericardiocentesis. Pericardial fluid should be tested for bacterial/ fungal/ TB causes. Blood culture too. * ESR - elevated consistent with inflammatory state * CRP - elevated consistent with inflammatory stat * Urea - elevated suggests uraemic cause- elevated above 21.4 mmol/L or 60 mg/dL suggests renal failure * FBC - Leukocytosis - infectious cause * CXR - usually normal unless large pericardial effusion - cardiothoracic ratio will be raised. Also looking for lung pathology. * Echocardiography --\> indicated when cardiac tamponade is suspected and differentiates from ACS. Looking to image pericardial effusion. * can do Chest CT/ cardiac MRI --\> echocardiogram inconclusive this can also detect pericardial effusion

Answer 9

* CXR - pulmonary infiltration, air bronchograms, pleural effusion * WBC content * sputum culture * blood culture

Answer 10

ECG - to exclude MI CXR - may show haemomediastinum or pleural effusion - haemothorax CT: tranverse cross section to show flap of aorta with true and false lumens. Weakening or aortic wall leads to tearing of tunica intima which creates a flap. Blood fills this space and gradually continues to tear the tunica intima distally to the site of origin which forms a false lumen. Blood fills the medial layer of the aortic wall. Echocardiography --\> may show tamponade or aortic regurgitation Transoeshophageal echocardiogram - can image entire thoracic aorta up except small portion of distal ascending aorta near arch.

Answer 11

* STEMI/ NSTEMI * aortic dissection * myocarditis * pericarditis * PE * tension pneumothorax

Answer 12

**NSTEMI:** * aims: relieve pain, identify and treat life threatening instability, relieve ischeamia, prevent further thrombosis or embolism, correct haemodynamic abnormalities * **Oxygen** -\> in pts that are hypoexamic, those in respiratory distress. * **Antiplatelet therapy --\>** * **Aspirin** - indicately immediated for pts with ACS (unless contraindicated) * **P2Y12 receptor inhibitors** (clopidogrel/ ticagrelor/ prasugrel) - inhibit platelet activation and adhesion/aggregation. * all patients should be placed on longer term dual antiplatelet therapy * **Pain relief** * **sublingual GTN --**\> reduced myocardial o2 demand and enhances oxygen delivery to myocardium (not given if R ventricular infarction or if recent phosphodiesterase 5 inhibitor use e.g. sildenafil (viagra)) * intravenous GTN if 3 sublingual GTN doses ineffective * **Intravenous morphine** if pain continues * **Beta Blockers** * used in all pts without contraindications * cardioselective preferred for initial tx - atenolol and bispropolol * post NSTEMI - metoprolol or bispropolol * (Calcium channel blockers -\> given to pts with continuing or recurrent ischaemic sx after nitrate and beta blocker therapy if ineffective ) * High risk patients need urgent coronary angiography and revascularisation if suitable * high risk = continuous angina despite therapy, rise of cardiac markers, signs HF, arrhythmias, PCI within 6 month, prior CABG, renal dysfunction, diabetes, reduced LV function. * Invasive approach - anticoagulation therapy (LMWH, UFH or fondaparinux ) and antiplatelet therapy before angiogram. PCI with angioplasty, alone or with a stent. * conservative approach - anticoagulation tx plus aspirin and P2Y12 receptor inhibitor for 48 hrs. (LMWH, UFH, fondaparinux).

Acute Central Chest Pain Flashcards

(38 cards)