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AAClinical school conditions > CPC 4 Chest pain and hypertension > Flashcards

CPC 4 Chest pain and hypertension Flashcards

1
Q

Atypical presentations of myocardial infarction

A 
Back, shoulder or jaw pain.
Sweating
Nausea
Lightheaded/dizzy, fatigued
Breathless
Anxiety
ALL THESE ARE MORE COMMON IN WOMEN.
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2
Q 
Differential diagnoses of chest pain, by anatomy:
Pleura
Lung
GIT
Aorta
Musculoskeletal
Heart.
A 
Pleura: effusion, pneumothorax, malignancy
Lung: infection, tumour, infarct, PE.
GIT: stomach, perforation, oesophagitis.
Aorta: aneurysm, dissection
Musculoskeletal
Heart.
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3
Q

Differential diagnoses of chest pain, by anatomy - anatomical areas.

A 
Pleura
Lung
GIT
Aorta
Musculoskeletal
Heart.
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4
Q

Cause of interscapula pain

A

Aortic dissection

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5
Q

Cause of pleuritic pain

A

Pulmonary embolus

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6
Q

Cause of positional pain

A

Pericarditis

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7
Q

Signs of aortic dissection

A

Unequal BP L/R UL, absent pulse

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8
Q

Signs of congestive heart failure

A

Raised JVP, gallop S3, Pulmonary oedema

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9
Q

How to establish the diagnosis of an MI

A

a rise or fall in cTn between first assessment and repeat 3-6hr later, coupled with a strong pre-test likelihood.

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10
Q

What are D-dimers?

A

Fibrin degradation products released from thrombi by

fibrinolysis

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11
Q

When are D-dimers raised

A

PE, DVT, pregnancy, after surgery, inflammation or
malignancy etc
Used to rule out PE as high negative predictive value.

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12
Q

Where do fibrofatty plaques occur?

A

At sites of decreased haemodynamic shear stress e.g artery bifurcations.

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13
Q

Clinical events caused by fibrofatty plaques

A

Renal failure and hypertension, intestinal angina (mesenteric), angina pectoris (coronary), carotid stenosis, aortic aneurysm.

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14
Q

Pleural causes of chest pain

A

Effustion, pneumothorax, malignancy

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15
Q

Lung tissue causes of chest pain

A

Infection, tumour, infarct, PE

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16
Q

GIT causes of chest pain

A

Stomach ulcer/perforation, GORD, oesophagitis.

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17
Q

Aortic causes of chest pain

A

aneurysm, dissection

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18
Q

Name the key coronary arteries

A

Left anterior descending artery, the circumflex artery, the right coronary artery.

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19
Q

Causes of pansystolic murmurs

A

MR, VSD

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20
Q

Cause of pericardial rub

A

pericardial effusion

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21
Q

Other name for costochondritis

A

Tietze’s Syndrome

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22
Q

Name all the cardiac biomarkers in blood

A

Trop I and Trop T (good)
CK-MB and myoglobin (fall rapidly).
CK and LDH (slight rise)

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23
Q

Most important risk factors for CVD: non-modifiable, behavioural, medical

A

Non-modifiable: age, gender, PMH, FH.
Behavioural: Smoking
Medical: Htn, DM, high LDL, low HDL.

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24
Q

How does smoking cause CVD

A

Endothelial damage

Incr. thrombus formation/platelet activation.

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25
Q

What is a lipoprotein

A

A macromolecular complex of lipids and proteins held together by non-covalent forces. They are required for transport of lipids both intra- and extra-vascularly.

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26
Q

Secondary causes of hypercholesterolaemia

A 
Hypothyroidism
Nephrotic syndrome
Immunoglobulins
Cholestasis
Anorexia
Cyclosporins, sirolimus, anti-epileptics.
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27
Q

Secondary causes of mixed hyperlipidaemia

A

Nephrotic syndrome

Hypothyroidism

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28
Q

Secondary causes of hypertriglyceridaemia

A 
T1 and 2 DM
CRF
Obesity
Alcohol
Hypothyroidism
Immunoglobulins
Oestrogens, corticosteroids, progestogens, protease inhibitors, retinoids.
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29
Q

How can you split primary dyslipidaemias?

A

Disorders of synthesis and secretion.

Disorders of metabolism.

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30
Q

What is familial hypoercholesterolaemia?

A

An inherited genetic defect leading to raised LDL-C levels from birth and hence premature atherosclerosis. Underdiagnosed.

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31
Q

Complications of fibrofatty plaques

A

Fissuring or ulceration
Calcification
Mural thrombus
Rupture

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32
Q

What can cause coronary artery occlusion?

A 
Thrombus
Plaque haemorrhage
Coronary artery dissection
Vasospasm
Embolic (vegetations, mural thrombus, paradoxical emboli)
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33
Q

Ischaemia effects on the myocardium

A

ATP depletion within seconds
Loss of contractility in under 2 minutes.
ATP 60 minutes.

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34
Q 
Timescale of morphological changes post-MI:
0.5-4 hr
4-12 hr
12-24 hr
1-3 days
3-7 days
7-14 days
2-8 weeks 
> 2 months
A 
0.5-4 hr  - No change
4-12 hr - Faint mottling
12-24 hr - Dark mottling
1-3 days - Yellow infarct centre
3-7 days - Hyperaemic border
7-14 days - Yellow core, red margin.
2-8 weeks - Scar formation 
> 2 months - Scar complete
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35
Q

Risks of reperfusion after MI

A

Reperfusion injury
Myocardial stunning
Haemorrhage
Early rupture

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36
Q

Causes of acute ischaemia

A

Inadequate supply: coronary artery stenosis, thrombus, dissection & spasm, microcirculatory dysfunction, anaemia.
Excessive demand: LV hypertrophy, LV dilatation.

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37
Q

MI complications (immediate)

A

Contractile dysfunctions
Arrhythmias
Myocardial ruptures

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38
Q

How much fluid is needed in the pericardium to cause acute tamponade

A

200-300 ml

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39
Q

MI complications (chronic)

A 
Pericarditis
Infarct expansion
Mural thrombus
Ventricular aneurysm
Progressive heart failure.
40
Q

When is secondary hypertension likely to be the cause of asymptomatic hypertension?

A

In a patient

41
Q

What are the causes of secondary hypertension

A 
Renal (>80%)
Endocrine disease
Coarctation of the aorta (in young)
Pre-eclampsia
Drugs
42
Q

What are some renal causes of hypertension

A

Chronic glomerulonephritis, chronic pyelonephritis, congenital polycystic kidneys, renal artery stenosis

43
Q

What are some endocrine causes of hypertension?

A

Conn’s syndrome, Cushing’s syndrome, phaeochromocytoma, acromegaly, diabetes, hyperparathyroidism

44
Q

What suggests a renal cause of hypertension

A

History of renal disease
Recurrent urinary tract infection
Certain drugs (inc losartan and aspirin)

45
Q

What is accelerated hypertension and what are its symptoms?

A

BP>200/130 : visual impairment, nausea, vomiting, fits, headaches

46
Q

What cause of secondary hypertension can also give you palpitations and sweating episodes?

A

Phaeochromocytoma.

47
Q

What test would you do to check renal impairment or Conn’s syndrome as a cause of hypertension?

A

Urea (renal impairment)

Electrolytes (hypokalaemia in Conn’s syndrome)

48
Q

Why would you do an ECG in someone with hypertension?

A

for left ventricular hypertrophy myocardial or ischaemia

49
Q

Why would you do a urine dipstick in someone with hypertension?

A

To check for haematuria/proteinuria

50
Q

Why would you do an MSSU and cytology for someone with hypertension?

A

To check for renal damage due to a possible infection and/or red cell casts.

51
Q

Why would you do a renal ultrasound in someone with hypertension?

A

To check the kidneys.

52
Q

Why would you do a CXR in someone with hypertension?

A

To look for heart failure and/or rib notching.

53
Q

Why would you do an echo in someone with htn?

A

For left ventricular hypertrophy.

54
Q

Which hypertensive patients would you do a urinary catecholamines or a magnetic resonance image of the renal arteries?

A

In those under 35 yr or where a secondary cause is suspected.

55
Q

What is carotid sinus syndrome?

A

A condition (generally in the elderly) where increased responsiveness of the carotid baroreceptors leads to arrhythmia or a drop in blood pressure.

56
Q

What is orthostatic hypotension

A

A greater than 20 mmHg drop in systolic blood pressure on standing.

57
Q

Chest pain relieved by nitrates

A

Fast: angina
Slow: oesophageal spasm

58
Q

Chest pain caused by meals

A

angina or oesophageal spasm

59
Q

Precipitating factors for pain from oesophageal disease

A

Food, lying flat, hot drinks, alcohol.

60
Q

Initial management of acutely ill patients with chest pain

A

Admit, check pulse and BP in both arms, JVP, heart sounds, check legs for DVT. Give O2 as necessary. IV line. Relieve pain (morphine + anti-emetic). Cardiac monitor, 12 lead ECG, CXR, ABG

61
Q

If a patient presents with shock and a raised JVP, what are they likely to have?

A

Cardiac tamponade.

62
Q

Questions if you suspect heart failure.

A

Orthopnoea, paroxysmal nocturnal dyspoea and peripheral oedema.

63
Q

What is cardiac catheterisation used for in coronary artery disease?

A

Diagnostic

Therapeutic (angioplasty, stent insertion)

64
Q

What is cardiac catheterisation used for in valvular disease?

A

Diagnostic

Therapeutic valvuloplasty

65
Q

What is cardiac catheterisation used for in congenital heart disease?

A

Diagnostic

Therapeutic - balloon dilatation or septostomy.

66
Q

Pre-procedural checks for cardiac catheterisation

A 
Peripheral pulses, bruits, aneurysms
FBC, U&Es, LFTs, clotting screen, CXR, ECG
Consent for all possibly eventualities
IV access
Nil by mouth for 6 h prior
67
Q

Indications for trans-oesophageal echocardiography

A

Diagnosing aortic dissection, assessing prosthetic valves, finding cardiac source of emboli

68
Q

Contra-indications for trans-oesophageal echo

A

Oesophageal disease or cervical spine injury.

69
Q

Uses of echocardiography

A

Quantification of global LV function, right hear haemodynamics (e.g regurg), congenital heart disease, endocarditis, pericardial effusion and HCM.

70
Q

Causes of angina pectoris

A

Common: atheroma
Rarely: anaemia, AS, tachyarrhythmias, HCM, arteritis or small vessel disease.

71
Q

Types of angina

A

Stable, unstable, decubitus and Prinzmetal’s.

72
Q

Angina on ECG

A

Usually normal, can show ST depression, flat or inverted T waves, signs of past MI.

73
Q

Angina management

A 
Lifestyle changes
Aspirin
B-blockers
Nitrates
Long acting calcium antagonists (amlodipine, diltiazem)
Nicorandil
74
Q

Indications for an angina referral

A

New angina of sudden onset, recurrent if past MI or CABG, uncontrolled by drugs, or unstable.

75
Q

Indications for percutaneous transluminal coronary angioplasty

A

Poor repsonse or intolerance to medial therapy, refractory angina in patients not suitable for CABG, previous CABG, post-thrombolysis if severe stenosis, symptoms or positive stress test.

76
Q

Should PTCA be accompanied by stenting?

A

Usually yes and with clopidogrel.

77
Q

What investigations should you do with a patient with known CAD and typical pain?

A

No further investigation needed.

78
Q

What investigations should you do with a patient with known CAD and atypical pain?

A

Either exercise testing or functional limitation

79
Q

What investigations should you do with a patient with unknown CAD?

A

Stratify likelihood of CAD.
Low risk - reconsider
Low-middle risk - CT with cororanry artery calcification scor.
Middle risk - functional imaging
High-ish risk angiography
Very high risk, treat as CAD (smoking, diabetic, hyperlipidaemia, over 45).

80
Q

Treatment for Prinzmetal’s angina

A

Calcium channel blockers and long-acting nitrates. Avoid aspiring and B-blockers.

81
Q

Who presents with silent MI?

A

The elderly and diabetics.

82
Q

How does silent MI normally present?

A

Syncope, pulmonary oedema, epigastric pain and vomiting, post-operative hypotension, oliguria, confusion, stroke and diabetic hyperglycaemic states.

83
Q

Blood tests for suspected ACS

A

FBCs, U&Es, glucose, lipids.

Cardiac enzymes - cardiac troponin, creatine kinase, myoglobin.

84
Q

Differentials for ACS

A

Angina, pericarditis, myocaarditis, aortic dissection, pulmonary embolism and oesophageal reflux.

85
Q

Management of ACS without ST segment elevation - MANABA(CW)

A 
Admit to CCU
Monitor O2 stats and administer if necessary
Analgesia
Nitrates
Aspirin
B-blocker
Antithrombotic e.g. fondaparinux or LMWH
(Clopidogrel, or if high risk GPIIb/IIIa antagonist e.g. tirofiban. Warfarin)
86
Q

If a patient with ACS comes in, and during monitoring proves to be high risk (rise in trop, changes to ECG, upon history taking), what do you do?

A

Infuse a GPIIb/IIIa antagonist and refer for angiography

87
Q

If a patient with ACS comes in, and during monitoring proves to be low risk, what do you do?

A

Discharge if repeat trop is negative. Arrange further investigation.

88
Q

Pre-hospital ACS management

A

Ambulance, 300mg aspirin chewed, GTN sublingual, analgesia and metoclopramide.

89
Q

Management of ACS with ST elevation. ABACW

A 
Angioplasty or thrombolysis
B-blocker
ACE inhibitor
Clopidogrel
Warfarin
90
Q

What kind of MI is most commonly followed by 1st degree heart block?

A

An inferior MI.

91
Q

What is Dressler’s syndrome?

A

Recurrent pericarditis, pleural effusions, fever, anaemia and raised ESR post MI.

92
Q

Causes of myocarditis

A

Idiopathic, viral, bacterial, spirochaetes, protozoa, drugs (herceptin, penicillin, chloramphenicol).

93
Q

Symptoms and signs of myocarditis

A

Fatigue, dyspnoea, chest pain, fever, palpitations, tachycardia.

94
Q

Associations with dilated cardiomyopathy

A

Alcohol, increased BP, haemochromatosis. Many others.

95
Q

Hypertrophic cardiomyopathy - inheritance and presentation.

A

Autosomal dominant inheritance - commonest cause of sudden cardiac death in the young. Can present with angina, dyspnoea, palpitation, syncope

96
Q

Clinical features of pericardial effusion

A

Dyspnoea, raised JVP, bronchial breathing at left base.

97
Q

Most common type of oesophageal cancer

A

Adenocarcinoma

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