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CVS > CVS 9 Chest Pain + Acute Coronary Syndromes > Flashcards

CVS 9 Chest Pain + Acute Coronary Syndromes Flashcards

1
Q

Where does chest pain occur?

A

Front + lateral aspect of chest

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2
Q

Areas which can cause chest pain

A

Cardiac- cardiac muscle + pericardial sac
Respiratory - lungs + pleura
Gastro-intestinal - Oesophagus + Peptic ulcer disease
Vascular - Aortic dissection
MSK - muscle, bone, costochondritis, cartilage
Skin

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3
Q

What skin condition can cause chest pain?

A

Shingles

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4
Q

Where is chest pain caused by cardiac issues felt?

A

Central

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5
Q

What respiratory condition can cause chest pain?

A

Pneumonia

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6
Q

What could a patient with a respiratory condition present with that a patient with acute contrary syndrome wouldn’t?

A

Coughing
Fever

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7
Q

Where is chest pain caused by respiratory issues felt?

A

Antero-laterally

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8
Q

Difference in location of chest pain caused by cardiac vs respiratory issues?

A

Cardiac - central
Respiratory - antero-lateral

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9
Q

Features of pleuritic chest pain

A
  • Sharp, well localised
  • Antero-lateral
  • Worsening with breathing in or coughing
  • Indicates involvement of structures with somatic innervation e.g. lung pleura, MSK structures, pericardial sac
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10
Q

What nerves innervate cardiac chest pain?

A

Visceral nerves

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11
Q

Where is pain from in pleuritic chest pain?

A

Lung pleura
Pericardial sac
MSK structures

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12
Q

What nerves innervate pleuritic chest pain?

A

Somatic nerves

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13
Q

Features of cardiac chest pain

A

Dull/heaving
Poorly localised
Central
Can radiate to jaw, neck, shoulder + arm
Worsens with exercise
Indicates involvement of heart muscle (visceral nerves)

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14
Q

Why is cardiac chest pain felt centrally (+ radiation to arm)?

A
  • Cardiac ischaemia stimulates visceral nerve endings
  • signals sent to spinal cord segments T1-T4/5
  • sensory afferent from T1-T4/5 Dermatomes of skin
  • brain interprets pain as arising from skin
  • pain perceived as arising from chest (+ limbs innervated by T1-T4/5)
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15
Q

What Dermatomes are involved in cardiac chest pain?

A

T1-T4/5

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16
Q

Cardiac causes of chest pain

A

Pericardium - pericarditis
Cardiac muscle - stable angina
- acute coronary syndromes

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17
Q

What is costrochondritis?

A

Inflammation of costal cartilage

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18
Q

Typical history of pericarditis

A

Male > female
Often virally caused
Previous viral infection
Eased with sitting forwards
Worsened when lying supine/flat

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19
Q

What worsens the pain of pericarditis?

A

Lying supine/flat

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20
Q

What eases the pain of pericarditis?

A

Sitting forwaeds

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21
Q

What does pericardial rub sound like?

A

Scratchy/scrapy sound

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22
Q

Further investigations of pericarditis

A

ECG
Blood tests

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23
Q

ECG of pericarditis

A

Saddle shape ST elevation
Widespread - across all leads

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24
Q

What spectrum of conditions does acute coronary syndrome describe?

A

Unstable angina
Myocardial infarction
STEMI
NSTEMI

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25
Q

What is a STEMI?

A

ST elevation myocardial infarction

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26
Q

What is an NSTEMI?

A

Non ST elevation myocardial infarction

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27
Q

What causes ischaemic heart disease?

A

Insufficient blood supply to heart muscles due to atherosclerotic disease of coronary arteries

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28
Q

Compare risk factors of atherosclerosis vs acute coronary syndrome

A

The same

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29
Q

Risk factors of acute coronary syndrome

A

Age
Gender
Smoking
Hypertension
Diabetes mellitus
Alcohol
Infection
Obesity
Lack of exercise
Hyperlipidaemia

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30
Q

Describe the plaque in stable angina

A

Plaque is fixed - stable occlusion

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31
Q

What happens if an atherosclerotic plaque ruptures in a stable occlusion in stable angina?

A

Thrombus formation
Sudden increased occlusion
Acute coronary syndrome occurs

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32
Q

Describe a thrombus in a STEMI

A

Complete conclusion of vessel

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33
Q

Describe a thrombus in a NSTEMI

A

Small thrombus

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34
Q

What eases stable angina pain?

A

Relieved by rest

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35
Q

Key differential between stable angina and acute coronary syndrome

A

Stable angina - pain relieved by rest
ACS - pain at rest

36
Q

Are there any associated autonomic features with stable angina?

A

No

37
Q

ECG in stable angina

A

Normal

38
Q

Troponin test in stable angina

A

Not raised
No muscle death

39
Q

What feature causes increased troponin in blood?

A

Muscle death

40
Q

Similarities between pains of acute myocardial infarction + pericarditis

A

Felt centrally

41
Q

Differences between pains of acute myocardial infarction + pericarditis

A

MI - pain radiates to left arm + jaw
Pericarditis - worsens on lying down
- eases when leaning forward

42
Q

Differences between ECGs of STEMI + pericarditis

A

STEMI - ST elevation in V3 + V4 or aVF + II
Pericarditis - widespread saddle shaped ST elevation

43
Q

Which leads have ST elevation in anterior ischaemia?

A

V3+V4 anterior chest leads

44
Q

Which leads have ST elevation in inferior ischaemia?

A

aVF + II

45
Q

When does pain occur in stable angina?

A

With activity
Relieves with rest

46
Q

When does pain occur in unstable angina?

A

Pain at rest

47
Q

When does pain occur in NSTEMI/STEMI?

A

Pain at rest

48
Q

What autonomic features can occur with STEMI/NSTEMI?

A

Nausea + sweating

49
Q

ECG in unstable angina

A

ST depression
T wave inversion

50
Q

ECG in STEMI

A

ST elevation
V3+V5 - anterior
avF + II - inferior

51
Q

ECG in NSTEMI

A

ST depression
T wave inversion

52
Q

What distinguishes between unstable angina and NSTEMI

A

Both have ST depression + T wave inversion

Unstable angina - normal troponin
- no autonomic feature
NSTEMI - raised troponin
- associated autonomic features

53
Q

Troponin test in unstable angina

A

Normal
No muscle death

54
Q

Troponin test in myocardial infarction

A

Raised
Muscle death occurs

55
Q

Autonomic features in acute coronary syndromes

A

Pallor
Sweating
Nausea

56
Q

What are critical test if acute coronary syndrome is suspected?

A

ECG
Troponin

57
Q

What is stable angina characterised by?

A

Cardiac sounding pain only on exertion
Relieved by rest
Pain settles <15 minutes

58
Q

What are acute coronary syndromes characterised by?

A

Cardiac sounding chest pain at rest
Pain >15 mins
Possible associated autonomic features

59
Q

Pathology of an acute coronary syndrome

A

Atheromatous plaque rupture
Thrombus formation
Partial or full occlusion

60
Q

What causes a type 1 myocardial infarction?

A

Atherosclerotic plaque rupture, ulceration, erosion or dissection > thrombus in coronary arteries > decrease in blood flow / distal embolisation > myocardial necrosis > myocardial infarction

61
Q

What is type 2 myocardial infarction?

A

A condition other than coronary plaque instability contributes to decreased myocardial O2 supply
e.g.
Coronary artery spasm
Coronary endothelial dysfunction
Tachyarrthymias, bradyarrthymias
Anaemia
Respiratory failure

62
Q

Describe the assessment needed for acute coronary syndromes

A

Cardiac sounding?
Radiation?
What eases pain?
What worsens the pain?
How long does it last?
Relieved with GTN?
Pleuritic? (Pain when breathing)
Any other symptoms

63
Q

Risk factors for acute coronary syndrome

A

Smoker
High cholesterol
Thrombophilia
Familia Hyperlipidaemia
Hypertension

64
Q

What is GTN?

A

Glyceryl trinitrate
Vasodilator

65
Q

What is used to treat angina?

A

GTN

66
Q

What leads suggest septal infarct?

A

V1
V2

67
Q

What leads suggest anterior infarct?

A

V1-V6

68
Q

What leads suggest inferior infarct?

A

II
III
aVF

69
Q

What does a ST elevation imply?

A

Sudden occlusion

70
Q

What does a T wave inversion imply?

A

Under supply of blood to myocardium
Not sudden occlusion

71
Q

What does a ST depression imply?

A

Under supply of blood to myocardium
Not sudden coronary occlusion

72
Q

Blood test for NSTEMI

A

Troponin - raised
Cholesterol
Renal function
HbA1C (blood glucose)
Haemoglobin (anaemic?)

73
Q

How is troponin measured?

A

Immunoassay

74
Q

When is troponin raised after cardiac muscle death?

A

3 hours

75
Q

How long does troponin remain elevated for after cardiac muscle death?

A

2+ weeks

76
Q

What is an echocardiogram?

A

Scan used to look at heart + vessels
Type of ultrasound

77
Q

Management of STEMI

A
  • Chewable aspirin 300mg
  • ticagrelor
  • IV morphine with metoclopramide
  • 2 puffs nitrate under tongue if high BP - GTN
  • Direct transfer to cardiac catheter labs for PCI
78
Q

What is percutaneous coronary intervention?

A

Group of minimally invasive procedures used to open clogged coronary arteries

79
Q

Management of NSTEMI

A
  • Antiplatelets + antithrombin - aspirin, ticagrelor
  • Anti-ischaemic - bisopolol, GTN infusion
  • Secondary prevention - statin, ACE inhibitors
80
Q

When is urgent PCI needed in NSTEMIs?

A

If patient has ongoing CP with dynamic ECG changes
If patient develops arrythmias with compromise

81
Q

Management of acute coronary syndromes

A

Lifestyle changes - low fat + salt diet, regular exercise
Dual anti platelets for 12 months
Aspirin for life
Statins to lower cholesterol
Bisoprolol
ACE inhibitors

82
Q

Why does chest pain in a patient with stable angina come on with exercise?

A

Blood flow through the left coronary artery is compromised due to shorter diastole + O2 demand has increased

83
Q

What is the primary mechanism by which GTN spray alleviates myocardial ischaemia in a patient with stable angina?

A

Dilation of systemic veins

84
Q

Modifiable risk factors of ACS

A

Smoking
Hypertension
Diabetes
Obesity

85
Q

Non-modifiable risk factors of ACS

A

Gender M>F
Older age
Family history

86
Q

Why is cardiac chest pain poorly localised whereas pleuritic chest pain is well localised?

A
  • Cardiac chest pain is innervated by visceral nerves which arises from splanchnic part of lateral plate mesoderm
  • whereas pleuritic chest pain is somatic nerves

CVS (17 decks)

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