Chest Pain

Question 1

what is angina

Answer 1

discomfort in chest due to NARROWING of coronary arteries and myocardial ischaemia

Question 2

typical v atypical angina

Answer 2

criteria:

• discomfort in chest radiating to arms, neck, jaw
• worse on exertion
• relieved by GTN spray after 5 minutes

typical = all this criteria
atypical = 2 of these

Question 3

what is the first line treatment for stable angina

Answer 3

GTN spray, 1 dose, 5 minutes, 2nd dose, 5 minutes, then if not relieved = ambulance

Question 4

what is the long term management for stable angina

Answer 4

1st line: beta blockers - bisoprolol, or CCB (amlodipine)
2nd line: BOTH these
3rd line: ivabradine, nicorandil or ranolazine

and also start on low-dose 75mg aspirin as secondary prevention of CVD

Question 5

what do you do if no drugs are working for angina

Answer 5

CABG, or PCI if CABG not appropriate

Question 6

what is unstable angina

Answer 6

angina that is severe and follows no patterns or triggers

Question 7

what is variant angina

Answer 7

severe pain at night and early morning due to vasospasm of CA = narrowing due to SM contraction

Question 8

what are the ECG changes in variant angina

Answer 8

ST elevation only during attack and increase in cardiac enzymes

Question 9

how do you manage variant angina

Answer 9

nitrates, CCB, NOT beta-blockers

Question 10

what is cardiac syndrome X

Answer 10

signs of myocardial ischaemia but with normal coronary arteries

Question 11

how do you diagnose ACS

Answer 11

• high troponins
• symptoms of ischaemia
• echocardiography
• stress tests
• identify intracoronary thrombus by angiography
• ECG

Question 12

what does an abnormal ECG in ACS show?

Answer 12

• transient ST elevation indicating an MI
• ST depression (this and t wave inversion is normally a NSTEMI)
• T wave inversion

Question 13

what are the 3 complications of an MI?

Answer 13

decreased contractility = coronary vessel perfusion is reduced
atypical conduction = arrtyhmias
tissue necrosis = inflammation, pericarditis and papillary muscles are damaged

Question 14

what is cardiac tamponade?

Answer 14

fluid or blood in the pericardial sac

Question 15

what are the ECG signs of a STEMI

Answer 15

• ST elevation (and reciprocal depression in the others)

Question 16

what are the pharmacological treatments for STEMI

Answer 16

oxygen
morphine
nitrates
300 mg aspirin

Question 17

what are the time limits and surgical interventions for a STEMI

Answer 17

PCI within 12 hours if you can get there within 2 hours

if not - thrombolysis and rescue PCI if residual ST elevation

Question 18

what is thrombolysis and how do you give it

Answer 18

alteplase, single IV bolus

Question 19

what is the imaging used for an NSTEMI

Answer 19

ECG = should show ST depression
transthoracic echo
stress echo
cardiac MRI
CT coronary angiography

Question 20

what is the surgical management for an NSTEMI or unstable angina

Answer 20

coronary angiography with follow on PCI within 96 hours of first admission

Question 21

how do you treat an NSTEMI (non-emergency) - after an ECG shows

Answer 21

fondaparinux
300mg aspirin
clopidogrel longer term

Question 22

what is the GRACE score and what does it include

Answer 22

indicates ischaemic risk in hospital and from 6m-3y

age, heart rate, systolic BP, ST segment deviation, troponins, cardiac arrest at admission

Question 23

what is the CRUSADE score and how does it work

Answer 23

indicates bleeding risk

Baseline haematocrit, GFR, HR on admission, systolic BP, prior stroke, history of DM, signs of CHF on admission, female sex

Question 24

what is the QRISK tool

Answer 24

estimating the 10 year risk of having a cardiovascular event in people who do not already have heart disease

Question 25

what is the long term prevention after an MI for CV events

Answer 25

• aspirin for life
• dual anti-platelets for 12 months
• statins: atorvastatin 20mg if qrisk >10%
• beta-blockers if LVEF <40%
• ACE-I or ARB for all

Question 26

when are troponins raised and why

Answer 26

in a STEMI or NSTEMI

because when cardiac muscle is damaged the membraine is disrupted so trop leaks out of cell and into blood

Question 27

what is the commonest complication after an MI

Answer 27

arrythmias

Question 28

what is v fib

Answer 28

when heart loses ability to contract and circulate blood to rest of the body

the cells are no longer conducted by the nodes, and fire randomly leading to ventricular wall spasming

blood stays in heart and cannot go to rest of the body

Question 29

symptoms of v fib

Answer 29

collapse, no consciousness and no pulse
cyanosis
before, they may have MI symptoms bc lack of oxygen

Question 30

risk factors for v fib

Answer 30

irritability to ventricular cells bc high Mg or high K or coronary artery blockage

scar tissue formation - MI, dead tissue replaced by protein scars, cardiomyopathy

Question 31

what is v tach

Answer 31

high HR >100bpm arising from ventricles at rest

reduced time to fill between beats and hence no forward movement of blood flow from ventricles

Question 32

symptoms of v tach and ECG changes

Answer 32

SOB, chest pain, palpitations, light headedness

wide QRS and tachycardia

Question 33

what is SVT

Answer 33

tachycardia arising from AVN or above

Question 34

types of SVT

Answer 34

A fib, paroxysmal SVT, atrial flutter and wolf-parkinson-white syndrome

Question 35

symptoms of SVT

Answer 35

o Palpitations
o Chest pain
o Anxiety
o Short of breath

Question 36

diagnosis of SVT

Answer 36

symptoms

ECG - no p waves

Question 37

what is atrial fibrillation

Answer 37

atrial spasming signalling the AV node erratically which leads to irregular rhythm

Question 38

ECG changes in a fib

Answer 38

distance in RR interval is different each time
no p waves
irregularly irregular

Question 39

risk factors for a fib

Answer 39

decreased atrial tissue
age 
inflammation
enlarged atria due to HT, valve or lung disease
hormonal abnormalities
alcohol abuse

Question 40

management of A fib

Answer 40

beta-blockers

anti-coagulant

Question 41

what medication should you not give a patient with low blood pressure and chest pain

Answer 41

nitrates - vasodilator and hence would lower the blood pressure more