Chest Pain

Question 1

Define stable angina

Answer 1

Chest pain resulting from myocardial ischaemia that is precipitated by exertion and relieved by rest.

Question 2

Most common cause of stable angina

Answer 2

Atherosclerotic disease

Question 3

Define decubitus angina

Answer 3

symptoms occur when lying down

Question 4

Define prinzmetal angina

Answer 4

symptoms of angina caused by coronary vasospasm

Question 5

Define coronary syndrome X

Answer 5

symptoms of angina but with normal exercise tolerance and normal coronary angiograms

Question 6

Medical Mx of stable angina (3 therapeutic targets)

Answer 6

• Anti-anginals (BB/CCB)
• Symptomatic (GTN spray)
• Risk factor reduction (aspirin, statins, ACEi)

Question 7

Define ACS and the three types

Answer 7

A constellation of symptoms caused by sudden reduced blood flow to the heart muscle.
Unstable angina
STEMI
NSTEMI

Question 8

Which populations are prone to silent infarcts

Answer 8

Elderly and diabetics

Question 9

Define unstable angina

Answer 9

Chest
pain at rest due to ischaemia without
cardiac injury

Question 10

Which artery is infracted in an inferior MI

Answer 10

right coronary artery

Question 11

Which artery is infracted in an anterior MI

Answer 11

left anterior descending

Question 12

Which artery is infracted in a lateral MI

Answer 12

left circumflex

Question 13

What ECG changes suggest a posterior MI

Answer 13

Tall R and T waves in V1-2 and ST depression in V1-3

Question 14

General ACS Mx (8)

Answer 14

Morphine
Oxygen
Nitrates
Antiplatelets (aspirin and clopidogrel)
Beta-blockers
ACEi
Statins
Heparin

Question 15

What is the aim of STEMI treatment

Answer 15

Coronary reperfusion either by PCI or fibrinolysis

Question 16

Mx of STEMI

Answer 16

Patient presenting < 12 hours from onset of symptoms
• Send to cathlab for PCI if it can happen within 120 mins of the time that fibrinolysis could have been administered
Patient presenting > 12 hours from onset of symptoms
• Coronary angiography followed by PCI if indicated

Question 17

Immediate Mx of NSTEMI/UAP

Answer 17

• Aspirin + other antiplatelet (e.g. clopidogrel, ticagrelor)
• Fondaparinux – if low bleeding risk unless coronary angiography planned within
24 hrs of admission
• Unfractionated heparin – if coronary angiography is planned

Question 18

After immediate Mx of NSTEMI

Answer 18

• HIGH risk
• GlpIIb/IIIa inhibitor (e.g. tirofiban)
• Coronary angiography (within 72 hours)
• LOW risk
• Conservative management (control risk factors)

Question 19

Complications of ACS

Answer 19

Death, Arrhythmia, Rupture, Tamponade, Heart failure

Valve disease, Aneurysm, Dressler’s syndrome, Embolism, Reinfarctio

Question 20

Which virus most commonly causes pericarditis

Answer 20

Coxsackie B

Question 21

Causes of AF (6)

Answer 21

Absolutely loads but the main ones are:
• Pneumonia
• PE
• Hyperthyroidism
• Ischaemic heart disease
• Alcohol
• Pericarditis

Question 22

Mx of AF

Answer 22

Treat the cause
  Rhythm Control
• < 48 hrs since onset of AF
• DC cardioversion
• OR chemical cardioversion
(flecainide or amiodarone)
• NOTE: flecainide is contraindicated if
there is a history of IHD
• > 48 hrs since onset of AF 🡪
anticoagulate for 3-4 weeks before attempting cardioversion

Rate Control
• Verapamil
• Beta-blockers • Digoxin

Question 23

Rate control drugs (3)

Answer 23

• Verapamil
• Beta-blockers
• Digoxin

Question 24

Is adenosine effective in AF

Answer 24

NO

Question 25

Is adenosine effective in atrial flutter

Answer 25

NO

Question 26

Which drugs are used in chemical cardioversion

Answer 26

flecainide or amiodarone

Question 27

What class of drug is verapamil

Answer 27

Non-dihydropyridine CCB

Question 28

What is CHADSVASC score used to calculate

Answer 28

Risk of having a stroke in the next ten years

Question 29

What happens in AVNRT

Answer 29

A local circuit forms around the AV node

Question 30

What happens in AVRT

Answer 30

• A re-entry circuit forms between the atria and ventricles due to the presence of an accessory pathway

Question 31

What is seen in an ECG of an SVT

Answer 31

* Regular * Narrow complex tachycardia * Absent p waves

Question 32

What is seen on the ECG after termination of SVT (AVNRT AVRT)

Answer 32

• AVNRT = normal • AVRT = ’Delta wave’ (slurred upstroke on QRS complex)

Question 33

4 steps in SVT Mx

Answer 33

STEP 1: is the patient haemodynamically stable? • NO 🡪 Synchronised DC cardioversion • YES 🡪 STEP 2 STEP 2: Vagal Manoeuvres – did it work? YES 🡪 Good Job NO 🡪 STEP 3 STEP 3a: IV Adenosine 6 mg – did it work? • YES 🡪 Good Job • NO 🡪 Step 3b, if that fails, Step 3c, then, Step 4 • STEP 3b: IV Adenosine 12 mg • STEP 3c: IV Adenosine 12 mg (again) ``` STEP 4: Choose from: • IV β-blocker (e.g. metoprolol) • IV amiodarone • IV digoxin • Synchronised DC cardioversion ```

Question 34

Which patients are adenosine contraindicated in and what should we use instead when managing SVT

Answer 34

E.g. asthma, we should verapamil instead

Question 35

4 signs Of HOCM

Answer 35

``` • Jerky carotid pulse • Double apex beat • Ejection systolic murmur/crescendo-decresendo murmur • Family history of sudden death at a relatively young age (< 65 yrs) ```