Case 1 - Chest Pain

Question 1

What are the 3 characteristics of “typical stable angina”

Answer 1

1) Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2) Precipitated by physical exertion
3) Relieved by rest of GTN within about 5 minutes

Question 2

What is “Atypical angina”

Answer 2

Chest discomfort which meets 2/3 of the typical angina characteristics

Question 3

What is the initial management for typical or atypical angina?

Answer 3

FBC test - test for anaemia which can exacerbate angina
Aspirin 75mg OD - unless contraindicated and only in stable angina
ECG - looking for changes associated with coronary artery disease
GTN spray - to relieve symptoms
Drug treatment - beta blocker or calcium channel blocker (only in stable angina)

Question 4

What are the changes on an ECG which are associated with coronary artery disease?

Answer 4

Pathological Q waves
Left bundle branch block
ST segment and T wave abnormalities (flattening or inversion)

Question 5

What are the ECG characteristics of LBBB?

Answer 5

Broad QRS complex
Deep S wave in V1
No Q wave in V5/V6

Question 6

In which ECG leads are Q waves normally not present?

Answer 6

V1-V3

Question 7

How would you advise someone to use their GTN spray?

Answer 7

Use when pain occurs
Stop what you are doing and rest
Use GTN spray as instructed - under tongue
Take 2nd dose in 5 minutes if pain has not eased
Call 999 for an ambulance if pain has not eased after another 5 minutes

Question 8

What are the types of coronary revascularisation available for patients with ACS?

Answer 8

Percutaneous coronary intervention (PCI) - using a balloon or a stent

Fibrolysis

Coronary artery bypass grafting (CABG)

Question 9

What does an aortic stenosis murmur sound like and where is it best heard?

Answer 9

Ejection click murmur between S1 and S2
Heard best at left 2nd intercostal space, left sternal edge
Murmur can radiate to carotid arteries in the neck

Question 10

What does a mitral Regurgitation murmur sound like and where is it best heard?

Answer 10

Pan systolic murmur between S1-S2

Best heard at the apex

Question 11

What does an aortic regurgitation sound like and where is it best heard?

Answer 11

Early diastolic murmur - between S2-S1

Best heard at 4th intercostal space with patient sat forward in expiration

Question 12

What does a mitral stenosis murmur sound like and where is it best heard?

Answer 12

Heard between S2-S1 Opening snap and mid diastolic rumble
Loud S1 sound
Best heard at the apex with patient in left lateral position

Question 13

What might a 3rd heart sound indicate (S3)?

Answer 13

Caused by diastolic filling of the ventricle
Considered a normal varient in patients < 30 years
Heard in left ventricular heart failure - dilated cardiomyopathy, constrictive pericarditis and mitral regurgitation

Question 14

What is the immediate management for suspected ACS?

Answer 14

Loading dose of Aspirin 300mg
Physical examination 
Bloods - Troponin 
12 lead ECG - if this shows STEMI or new LBBB consider for coronary reperfusion therapy 
Beta blocker IV (unless contraindicated)
Oxygen/Monitor 
Consider clopidogrel in hospital 300mg

Question 15

What is the triad associated with Cardiac Tamponade?

Answer 15

Becks Triad - Low blood pressure (weak pulse), raised JVP, muffled heart sounds

Question 16

What are the possible complications following an MI?

Answer 16

Cardiac Arrest 
Cardiogenic Shock 
Chronic heart failure 
Tachyarrhythmias 
Bradyarrhythmias - more common after inferior myocardial infarctions 
Pericarditis - common in first 48 hours following 
Left ventricular aneurysm 
Left ventricular free wall rupture 
Ventricular septal defect 
Acute mitral regurgitation

Question 17

What is the difference between pericarditis and Dressler’s syndrome?

Answer 17

Pericarditis - occurs 48 hours after MI
Dresser’s syndrome - type of pericarditis that occurs 2-6 weeks following an MI, thought to be due to an autoimmune reaction against protiens as the myocardium recovers

Question 18

What is the management of a STEMI?

Answer 18

Aspirin, clopidogrel and unfractionated heparin
Primary percutaneous coronary intervention (PCI)
- thrombolysis should be performed in patients without access to primary PCI
Glycaemic control in patients with diabetes mellitus

Question 19

What are the drugs that patients should be on lifelong following an myocardial infarction?

Answer 19

Dual antiplatelet therapy (aspirin + clopidogrel)
ACE inhibitor
Beta Blocker
Statin

Question 20

What are the contraindications to thrombolysis?

Answer 20

Recent haemorrhage, trauma or surgery 
Coagulation and bleeding disorders
Stroke < 3 months 
Intracranial neoplasm 
Aortic dissection 
Pregnancy 
Severe hypertension

Question 21

What ECG changes would you see in 1st degree heart block?

Answer 21

Constantly prolonged PR interval

Question 22

What ECG changes would you see in 2nd degree heart block mobitz I?

Answer 22

Ever increasing PR interval until QRS complex drops

Question 23

What ECG changes would you see in 2nd degree heart block mobitz II?

Answer 23

ORS complexes dropped for no reason

Question 24

What ECG changes would you see in 3rd degree heart block?

Answer 24

No relationship between the P waves and the QRS complexes

Question 25

What ECG changes would you see with atrial flutter?

Answer 25

Saw tooth P waves

Question 26

How can anaemia cause myocardial ischaemia?

Answer 26

Fewer RBCs results in poorer oxygenation

Question 27

What are the non cardiovascular differentials of chest pain?

Answer 27

GORD
Gallstones
Peptic ulcer
Pancreatitis 
PE
Pneumothorax
Pneumonia 
Costochondritis

Question 28

What is the management for NSTEMI/Unstable Angina?

Answer 28

Aspirin 300mg stat 
Clopidogrel for 12 months afterwards 
Fondaparinux if not planning coronary angriography in 24 hours 
Calculate risk of MI using GRACE score 
Secondary prevention discussion

Question 29

What are the different lead orientations on an ECG?

Which arteries supply the areas?

Answer 29

I, aVL, V5, V6: lateral (left circumflex)
II, III, avF: inferior (right coronary)
V1, V2: septal (anteroseptal)
V3, V4: anterior (LAD)

Question 30

What arteries would be occluded in an anterior, inferior and lateral MI?

Answer 30

Anterior - Left anterior descending
Inferior - right coronary artery
Lateral - circumflex artery