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Year 3 - Medicine and Surgery book > Chest pain > Flashcards

Chest pain Flashcards

1
Q

Name 7 causes of acute chest pain in someone of 60 y/o

A 
Musculoskeletal inflammation
ACS
PE
Stable angina
Pleurisy
Oesophagitis
Pneumothorax
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2
Q

A young female on the COCP may be more likely to suffer from?

A

PE (COCP thrombogenic)
Pneumothorax (especially if tall and thin)
Cocaine induced coronary spasm

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3
Q

Which conditions presenting as chest pain require immediate management?

A 
ACS
Aortic dissection
Pneumothorax
PE
Boerhaave's perforation
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4
Q

What are the key features of ACS

A

Sudden onset central crushing chest pain radiating to either arm/neck/jaw
Lasts few minutes to 30 minutes/longer
Higher suspicion if PMH of exertion angina or MI or CVS RFs
Any signs of Brady/tachyarrhythmias

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5
Q

What are the signs of hypercholesterolaemia

A

Xanthomata
Xanthelasma
Corneal arcus

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6
Q

What are the signs of PVD

A 
Weak pulses
Peripheral cyanosis
Cold peripheries
Atrophic skin
Ulcers
Bruits upon carotid auscultation
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7
Q

Why is it important to look for signs of Brady/tachyarrhythmias

A

Brady/tachyarrhythmias cause drop in CO - reduced cardiac perfusion –> ischaemia
Arrhythmias commonly occur around scarred myocardium - from old infarcts but also acute infarcts (e.g. heart block/VT)

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8
Q

VT commonly presents as what instead of chest pain

A

Shock

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9
Q

What are the features of aortic dissection

A

Sudden onset tearing chest pain radiating to back
Absent pulse in one arm due to occlusion of brachiocephalic trunk or left subclavian artery
Hypertension or hypotension
Difference in BP in both arms
New onset aortic regurgitation - manifests as early diastolic murmur
Pleural effusion (common left sided) - pleural irritation due to dissected aorta
History of HTN (most important RF), smoking, atherosclerosis, recent aortic valve replacement

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10
Q

What are the features of pneumothorax

A

Sudden onset pleuritic chest pain with breathlessness (may also present as painless though)
Hyperinflated chest wall - limited expansion
Hyperresonance over affected area
Absent breath sounds over affected areas
Tracheal deviation

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11
Q

In tension pneumothorax, what is very important to remember

A

Pleural space gets gradually inflated with air -> deviates mediastinum and compress heart leading to cardiopulmonary arrest

Hence tracheal deviation away from pneumothorax requires urgent insertion of large bore cannula in MCL above 3rd rib to allow trapped air to escape

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12
Q

What are the features of PE (due to DVT)

A

Sudden onset SOB (+pleuritic chest pain + haemoptysis) and RFs for blood clots
Tachycardia
Signs of hypoxia - often clinically unseen

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13
Q

What are the features of Boerhaaves perforation

A

Very rare but associated with high mortality
Sudden onset severe chest pain immediately after vomiting
SOB and pleuritic chest pain maybe shortly afterwards
Signs of pleural effusion after some hours (dull percussion, absent breath sounds, decreased vocal resonance)
Subcutaneous emphysema?
Abdominal rigidity/sweating/fever/tachycardia/hypotension present as illness progresses but non-specific

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14
Q

If a patient has chest pain - what investigations should be done?

A

ECG
Blood tests - troponin, serum cholesterol, FBC, U&Es, inflammatory markers, capillary glucose, amylase
Imaging - erect CXR

Second line - d dimer

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15
Q

What are we looking for on an ECG for a patient who presents with chest pain

A

Look for signs of ischaemia or arrhythmias
If PE suspected, signs of right heart strain or tachycardia
Look for STEMI / new onset LBBB

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16
Q

What is the difference between CK-MB and troponin

A

Both look for damage to cardiac muscle
CK-MB falls back to normal within 2-3 days, Troponin levels remain high for over 7 days

NB troponins are really excreted so be careful when interpreting troponin levels in someone with renal failure

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17
Q

How do serum cholesterol levels change after an MI

A

Causes a decrease in total serum cholesterol, HDL and LDL within 24 hrs of infarct –> levels will not return to normal for 2-3 months post infarct

Hence measure cholesterol levels ASAP to guide future therapy

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18
Q

In U&Es, what should we pay particular attention to?

A

Potassium - this could be the cause of an arrhythmia

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19
Q

WCC and CRP are inflammatory markers. Raised levels of these may point to which conditions?

A

Pericarditis or Bornholm’s disease (ICM inflammation due to Coxsackie B virus)

Elevated CRP/WCC may also point to aortic dissection/MI

20
Q

Why should you check amylase levels?

A

Patients who have acute pancreatitis may also present with severe central chest pain and no epigastric tenderness.

21
Q

What do D-dimer levels show and why do we check it as a second line

A

D dimer is the breakdown product of fibrin clot - can be caused by recent surgery/trauma –> not diagnostic of PE/DVT

But low D-dimer can be used to rule out a DVT/PE

22
Q

What does ST depression in V1-V3 show?

A

Anterior NSTEMI or posterior infarct (treated like a STEMI)

23
Q

A patient has tearing pain radiating to the back, pulse and BP not equal in different arms and CXR shows wide mediastinum. What should you suspect?

How do you confirm

A

Aortic dissection

Confirm with CT angiography of chest or Transoesophageal echo —> looking for a false lumen

24
Q

How are all patients with ACS managed acutely? (MONABASH)

A
  1. Morphine (and metoclopramide)
  2. Oxygen - only if required
  3. Nitrates for vasodilation
  4. Antiplatelets - aspirin + clopidogrel (ADP receptor blocker)
  5. Beta-blocker - reduce myocardial O2 demand. CONTRAINDICATED if patient has heart block, asthma or signs of acute HF
  6. ACEi - reduces A2 mediated vasoconstriction, reduces remodelling which can cause arrhythmias
  7. Statins - improve endothelial function and reduce cholesterol. Also modulate inflammatory responses (CRP), prevent thrombus formation
  8. Heparin - LMWH given or fondaparinux, prevents coronary thrombosis
25
Q

STEMI patients should receive what within 12 hours of onset of pain

A

Thrombolysis or angioplasty - and ideally within 1 hour

angioplasty better bu time is the most important

26
Q

NSTEMI patients should be given angioplasty if severe acute criteria are met. What score is given for NSTEMI patients to stratify the risk of NSTEMI

A

GRACE score

27
Q

When do you give ACEi vs CCB vs thiazide diuretics

A

ACEi if less than 55 years and white, CCB/thiazide if >55 or non white

Can give a mix if one drug insufficient

28
Q

If statins are not tolerated, what is given?

A

Fibrins

29
Q

How isi thromboembolic risk decreased?

A

Aspirin and clopidogrel (ADP inhibitor)

30
Q

What makes a patient a candidate for ICD

A

If EF < 35% (severe LV dysfunction)

Conduction block on ECG

31
Q

What are the common complications of MI? (Darth Vader)

A 
Death
Arrhythmia
Rupture (either septum or outer walls)
Tamponade
Heart failure
Valve disease
Aneurysm
Dresslers Syndrome (autoimmune pericarditis)
Embolism
Reinfarction
32
Q

What are the differences between Dresslers syndrome and simple post MI pericarditis?

A

Post-MI pericarditis: more common, presents within 2-4 days

Dressler’s syndrome: autoimmune pericarditis, presents 2-10 weeks after MI

33
Q

What would test results show in someone with Dressler’s syndrome

A

Leukocytosis
ECG shows diffuse saddle-shaped ST elevation across several leads without reciprocal ST depression. May also show PR depression
ECG and CXR to exclude reinfarction/pulmonary pathology

34
Q

How to treat someone with Dressler’s syndrome?

A

Analgesia - NSAIDS and/or colchicine. PPI to prevent gastric irritation from NSAIDS. Consider pericardiocentesis if significant pericardial effusion.

Monitor renal function closely due to NSAIDS/ACEi

35
Q

How do you diagnose gallstones?

How do you diagnose oesophageal spasm?

A

Gallstones - using US

Oesophageal spasm - using barium swallow and oesophageal manometry (normal result doesn’t exclude it)
(May be better to do therapeutic trial - prescribe PPI and see if positive response)

36
Q

MI causes reciprocal changes in ECG. What does this mean

A

ST elevation in some leads –> ST depression in opposite anatomical leads

37
Q

If you have a tall, thin young individual, which diagnoses must you think of first?

A

Pneumothorax or Marfans syndrome predisposing to dissected thoracic aorta/dissected aortic aneurysm

38
Q

Most cases of aortic dissection will show what on CXR

A

Widened mediastinum

39
Q

Any aortic dissection involving the ascending aorta is classed as what type of dissection?

Wb dissections involving descending aorta?

A

Ascending aorta = Stanford Type A - SURGICAL EMERGENCY

Descending aorta = Type B - managed medically and only surgical if medical management fails

40
Q

N&V are commonly associated with which MIs?

A

Inferior

41
Q

N&V with a small unilateral pleural effusion indicates possibility of?

A

Boerhaaves syndrome

42
Q

How to distinguish MI and Boerhaaves without looking at troponin etc

A

MI = pain precedes vomiting

Boerhaaves = vomiting precedes pain

43
Q

What is the management of Boerhaaves syndrome

A

Prompt antibiotic therapy

Surgical repair of oesophagus with mediastinal washout

44
Q

Why do inferior MIs tend to cause N&V

A

Infarction of the inferior myocardium irritates the diaphragm

45
Q

On an ECG, how could you tell if a patient had a full thickness MI 2 years previously?

A

Pathological (deep) Q waves

Year 3 - Medicine and Surgery book (29 decks)

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