Amir Sam - Chest Pain

Question 1

What investigations do you do if someone comes in with chest pain?

Answer 1

ECG
Troponin

if positive coronary angiography
Exercise tolerance test
Echocardiography

Question 2

Differential diagnosis for chest pain?

Answer 2

Cardiac
Respiratroy
GI
MSK

Question 3

Cardiac causes of chest pain + what features/risk factors you’d look out for

Answer 3

IHD - look at risk factors
Aortic dissection - ask for blood pressure in two arms
Pericarditis - ask for fever

Question 4

Resp causes of chest pain

Answer 4

PE
Pneumonia
Pneumothorax

Ask about sputum, temperature, recent travel, onset etc

Question 5

GI causes of chest pain

Answer 5

Oesophageal spasm
Oesophagitis
Gastritis

Question 6

MSK causes of chest pain

Answer 6

Costrochondritis

Question 7

ST elevation is seen in Inferior

Answer 7

2,3, AVF

Question 8

Which artery is affected in anterior MI and which leads show ST elevation?

Answer 8

LAD

V1-4

Question 9

Which artery is affected in lateral MI and which leads show ST elevation?

Answer 9

Circumflex

V5,6, aVL

Question 10

Which artery is affected in inferior MI and which leads show ST elevation?

Answer 10

Inferior MI
RCA
2,3, aVF

Question 11

Differentials for collapse

Answer 11

Hypoglycemia

Vasovagal
Arrthymias
Outflow obstructions (AS, HOCM, PE)
Postural hypotension

Question 12

What might lead to tachyarrythmias?

Answer 12

Long QT syndrome (abnormal ventricular repolarisation)

Question 13

Causes of long QT syndrome + how to work it out on an ECG

Answer 13

Congenital mutation in potassium channels
Acquired - low potassium or magnesium
T wave should be before half way point between two R complexes

Question 14

Aortic stenosis features + where the murmur radiates to

Answer 14

Slow rising pulse
Ejection systolic murmur

radiates to carotids

Question 15

Murmur louder on inspiration

Answer 15

Right sided

Question 16

Differentials for raised JVP

Answer 16

RHF
Tricuspid regurg
CONSTRICTIVE PERICARDITIS

Question 17

Causes of RHF

Answer 17

Secondary to LHF

Pulmonary hypertension e.g. COPD

Question 18

Tricuspid regurgitation causes

Answer 18

Valve abnormalities

Right ventricular dilation

Question 19

Causes of constrictive pericarditis

Answer 19

Infection - TB
Inflammation - connective tissue diseases
Malignancy

ALSO DRESSLER’S
Metabolic - myxoedema, uremia,

Question 20

Differentials for systolic murmur

Answer 20

Ejection systolic - AS

Pansystolic - MR/TR/VSD

Question 21

Where does a VSD murmur radiate?

Answer 21

Left sternum

Question 22

Where does MR murmur radiate?

Answer 22

Axilla

Question 23

Heaves - centre of chest means

left of chest means

Answer 23

Centre - RVH

Left - LVhypertrophy

Question 24

Sinus tachycardia differentials

Answer 24

Sepsis
Hypovolaemia
PE
Endocrine (thyrotoxicosis, phaeochromocytoma)

Question 25

Causes of AFIB

Answer 25

Thyrotoxicosis Alcohol Heart - problems with muscle, valve or pericardium Lung - pneumonia, PE, cancer AKA Ischemia Infection

Question 26

SVT on an ECG

Answer 26

NO p waves | Regular fast QRS complexes

Question 27

SVT classifications

Answer 27

Reentry circuit due to AVNRT AVRT

Question 28

AVRT ECG (WPW)

Answer 28

Short PR interval | Slurred upstroke due to depolarisation down accessory pathway

Question 29

AVNRT vs AVRT on ecg

Answer 29

AVNRT - no slurred upstroke | but you do get the shortened PR interval

Question 30

VT ecg (compared to SVT)

Answer 30

BROAD COMPLEX tachycardias because the action potential is coming from ventricles, therefore takes a while to actually depolarise (unlike in SVT)

Question 31

Causes of VT

Answer 31

Ischemia Electrolyte abnormality Long QT

Question 32

SVT management and what to do if haemodynamically unstable

Answer 32

Valsalva manoeuvre Adenosine whilst on cardiac monitor DC cardioversion of haemodynamic compromise (AKA BP low)

Question 33

When do you do DC in SVT

Answer 33

Only if BP is dropping

Question 34

Management of AF if haemodynamically stable

Answer 34

DC If over 2 days, anticoagulate for 3-4 weeks before DC Rate control - beta blocker, digoxin TREAT UNDERLYING CAUSE AND ANTICOAGULATE FOR COMPLICATIONS (CHADVASCS)

Question 35

Causes of Afib

Answer 35

Infection in heart or lung Cancer Thyrotoxicosis Alcohol

Question 36

Management of VT if patient has a pulse

Answer 36

If BP stable - IV amiodarone + treat cause ICD

Question 37

If the patient has PULSELESS VT, what do you do?

Answer 37

DEFIBRILATE

Question 38

LVH in ECG

Answer 38

Deep S in V1/V2 Tall R in V5/6 If more than 7 large squares in total, suggests LVH

Question 39

On an ECG, ischemia is shown as?

Answer 39

ST elevation Inverted T waves Pathological Q waves

Question 40

What do pathological Q waves indicate?

Answer 40

Previous MI Q wave more than 1mm wide or 2mm deep or more than 1/4 of QRS depth

Question 41

What would need to look for on ECG for arrhythmias

Answer 41

Rate, rhythm Broad QRS - BBB QT PR interval

Question 42

What would you look at on ECG for hypertrophy

Answer 42

Axis R S

Question 43

What is S3 associated with?

Answer 43

Rapid ventricular filling

Question 44

What is S4 associated with?

Answer 44

Ventricular hypertrophy

Question 45

Acute heart failure management

Answer 45

``` Sit pt up Oxygen Furosemide IV Morphine and metoclopramide GTN infusion if needed Treat underlying cause ```

Question 46

Chronic heart failure management

Answer 46

ACEi BB Loop diuretic

Question 47

Cardiac arrest - what does the management depend on?

Answer 47

Whether it's shockable or not Shockable = VT or VF Non shockable = PEA (pulseless electrical activity) or asystole

Question 48

What is PEA?

Answer 48

When the heart isn't actually contracting due to lack of blood to myocytes from coronary arteries, but there is still electrical activity

Question 49

Management of cardiac arrest when there is shockable rhythm

Answer 49

``` Defib CPR Check ecg again If no improvement, repeat defib Then give ADRENALINE Then CPR Repeat cycle ``` If by third defib, no improvement, give amiodarone + treat reversible causes

Question 50

Management of cardiac arrest when there is NO shockable rhythm

Answer 50

CPR (2 min) Adrenaline every 3-5 min Atropine if <60bpm

Question 51

Causes of cardiac arrest

Answer 51

Four Hs + Four Ts toxin tamponade tension pneumothorax thrombosis Hypo/hyperkalemia Hypothermia Hypoxia Hypovolemia