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CVS 9 Chest Pain + Acute Coronary Syndromes Flashcards

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1
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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2
Q

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

A

Cardiac - central
Respiratory - antero-lateral

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3
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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4
Q

What nerves innervate cardiac chest pain?

A

Visceral nerves

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5
Q

What nerves innervate pleuritic chest pain?

A

Somatic nerves

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6
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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7
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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8
Q

What Dermatomes are involved in cardiac chest pain?

A

T1-T4/5

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9
Q

Cardiac causes of chest pain

A

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

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10
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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11
Q

What worsens the pain of pericarditis?

A

Lying supine/flat

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12
Q

What eases the pain of pericarditis?

A

Sitting forwaeds

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13
Q

ECG of pericarditis

A

Saddle shape ST elevation
PR depression
Widespread - across all leads

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14
Q

management of pericarditis

A
  • treat underlying cause
  • avoid strenuous activity until symptoms + inflammatory markers are resolved
  • NSAIDs or colchicine
  • aspirin
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15
Q

What is dressler’s syndrome?

A
  • post MI syndrome
  • occurs 2-3 weeks after acute MI
  • causes pericarditis
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16
Q

Presentation of Dressler’s syndrome

A
  • presents 2-3 weeks after acute MI
  • pleuritic chest paim
  • low grade fever
  • pericardial rub
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17
Q

Diagnosis of dressler’s syndrome

A
  • ECG - ST elevation + T wave inversion
  • echo - pericardial effusion
  • raised CRP + ESR
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18
Q

Management of dressler’s syndrome

A
  • NSAIDs
  • steroids if more severe
  • pericardiocentesis if pericardial effusion
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19
Q

What causes ischaemic heart disease?

A

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

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20
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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21
Q

Describe the plaque in stable angina

A

Plaque is fixed - stable occlusion

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22
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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23
Q

Describe a thrombus in a STEMI

A

Complete conclusion of vessel

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24
Q

What eases stable angina pain?

A

Relieved by rest

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25
Key differential between stable angina and acute coronary syndrome
Stable angina - pain relieved by rest ACS - pain at rest
26
Are there any associated autonomic features with stable angina?
No
27
Similarities between pains of acute myocardial infarction + pericarditis
Felt centrally
28
Differences between pains of acute myocardial infarction + pericarditis
MI - pain radiates to left arm + jaw Pericarditis - worsens on lying down - eases when leaning forward
29
Differences between ECGs of STEMI + pericarditis
STEMI - ST elevation Pericarditis - widespread saddle shaped ST elevation
30
ECG in unstable angina
ST depression T wave inversion
31
ECG in NSTEMI
ST depression T wave inversion
32
What distinguishes between unstable angina and NSTEMI
Both have ST depression + T wave inversion Unstable angina - normal troponin - no autonomic feature NSTEMI - raised troponin - associated autonomic features
33
What is stable angina characterised by?
Cardiac sounding pain only on exertion Relieved by rest Pain settles <15 minutes
34
What are acute coronary syndromes characterised by?
Cardiac sounding chest pain at rest Pain >15 mins Possible associated autonomic features
35
Pathology of an acute coronary syndrome
Atheromatous plaque rupture Thrombus formation Partial or full occlusion
36
What causes a type 1 myocardial infarction?
Atherosclerotic plaque rupture, ulceration, erosion or dissection > thrombus in coronary arteries > decrease in blood flow / distal embolisation > myocardial necrosis > myocardial infarction
37
What is type 2 myocardial infarction?
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*
38
What is *GTN*?
Glyceryl trinitrate Vasodilator
39
Drug management of angina
- aspirin + statin - **sublinguinal glycerl trinitrate** PRN - first line: **B blocker or CCB** - if CCB is used alone, verapamil or Diltiazem should be used - if with B blocker, amlopidine or nifedipine - *nicorandil*: K+ channel activator + vasodilation
40
What does a ST elevation imply?
Sudden occlusion
41
What does a T wave inversion imply?
Under supply of blood to myocardium Not sudden occlusion
42
What does a ST depression imply?
Under supply of blood to myocardium Not sudden coronary occlusion
43
Blood test for NSTEMI
Troponin - raised Cholesterol Renal function HbA1C (blood glucose) Haemoglobin (anaemic?)
44
How is troponin measured?
Immunoassay
45
When is troponin raised after cardiac muscle death?
3 hours
46
How long does troponin remain elevated for after cardiac muscle death?
2+ weeks
47
General management of ACS
- chewable aspirin 300mg - O2 if <94% - morphine if severe pain - IV or sublingual nitrate (not if pt is hypotensive)
48
Management of STEMI
- IV *morphine* with *metoclopramide* - Chewable *aspirin* 300mg > 75mg od for life - aspirin + clopidogrel + heparin - if PCI **p**ossible within 2 hours > give **p**raugrel + UFH - if **t**oo late > fibrinolysis (with Ateplase tPA) + dabigatran | **t**icagrelor after procedure - repeat ECG
49
Management of NSTEMI/unstable angina
- pain relief *morphine* - *aspirin* 300mg loading dose > 75mg od - *fonaparinix* if no immediate PCI planned - repeat ECG - estimate 6 month mortality using *GRACE* - if high risk (>3%) + clinically unstable: immediate **angiography** - if high risk (>3) + stable: **angiography** within 72 hours then **PCI** + *prasugrel + UFH* - if low risk > *ticagrelor* or *clopidogrel* if high bleeding risk
50
When is urgent PCI needed in NSTEMIs?
if patients estimated 6 month mortality if high risk >3% If patient has ongoing chest pain with dynamic ECG changes If patient develops arrhythmias with compromise
51
Management of acute coronary syndromes
Lifestyle changes - low fat + salt diet, regular exercise Dual anti platelets for 12 months *Aspirin* for life *Atorvastatin* 80mg *Bisoprolol* ACE inhibitors
52
Why does chest pain in a patient with stable angina come on with exercise?
Blood flow through the left coronary artery is compromised due to shorter diastole + O2 demand has increased
53
What is the primary mechanism by which GTN spray alleviates myocardial ischaemia in a patient with stable angina?
Dilation of systemic veins
54
Why is cardiac chest pain poorly localised whereas pleuritic chest pain is well localised?
- Cardiac chest pain is innervated by visceral nerves which arises from splanchnic part of lateral plate mesoderm - whereas pleuritic chest pain is somatic nerves
55
What order of ADP receptor antagonist should be given in management of STEMIs? What loading dose for each?
Prasugrel 60mg Clopidogrel 600mg Ticagrelor 180mg
56
Why are ACEi given in STEMI management?
To prevent muscle over damage
57
Causes of non-cardiac chest pain
- costrochondritis - GORD - PE - pneumonia - pneumothorax - shingles
58
Investigations of angina
- physical exam - ECG - FBC + U&Es - LFTs + lipid profile - thyroid function test - HbA1C + fasting glucose
59
Management of stable angina
**RAMPS** - **R**efer to cardiology - **A**dvise about diagnosis + managment - **M**edical treatment - *GTN + B blockers* - **P**rocedural or surgical interventions: *PCI* or *CABG* - **S**econdary prevention - aspirin
60
Medical management of stable angina
- sublingual glycerol trinitrate - beta blocker +/- CCB *e.g. Diltiazem or verapamil (both avoided in HFrEF*
61
Surgical interventions of stable angina
- percutaneous coronary intervention (balloon + stent) - coronary artery bypass graft
62
What are the 3 main options for graft vessels in a coronary artery bypass graft?
Saphenous vein Internal thoracic artery Radial artery
63
What is involved in a coronary artery bypass graft?
- **midline sternotomy incision** to open chest along sternum - graft vessel is attached to affected coronary artery > bypasses stenotic area - options for graft vessels: saphenous vein, internal thoracic artery or radial rtery
64
Compare PCI vs CABG scars
- **PCI**: brachial or femoral artery access - **CABG**: midline sternotomy, scar on inner leg (saphenous vein harvesting)
65
Causes of raised troponin
- NSTEMI/STEMI - chronic kidney disease - myocarditis - sepsis - aortic dissection - PE
66
Complications of myocardial infarction
- death (most commonly due to VF) - rupture of heart septum > VSD - heart failure - cardiogenic shock - arrhythmias - left ventricular aneurysm - pericarditis - Dressler’s syndrome - acute mitral regurgitation due to rupture of papillary muscles
67
Types of myocardial infarction
- **type 1**: traditional MI - sudden occulsion of vessel - **type 2**: ischamia secondary to increased demand or reduced supply of O2 - **type 3**: sudden cardiac death or caridac arrest suggestive off ischaemic event - **type 4**: MI assocaited with procedures such as PCI, CABG… (iatrogenic)
68
What is percutaneous coronary intervention?
- putting a catheter into patients radial artery - fed to coronary arteries via angiography guidance - angioplasty (balloons) used to widen lumen - stent left in place - then dual antiplatelet for 1 year - aspirin + clopidogrel then drop one
69
Outline thrombolysis
- injecting fibrinolytic agent *e.g. streptokinase or alteplase (tissue plasminogen activator)* + giving UFH or LMWH - breaks down fibrin in blood clots - give ticagrelor after - or clopidogrel if high bleeding risk
70
Complications of pericarditis
Cardiac tamponade Chronic pericarditis
71
Causes of pericarditis
- viral infection - idiopathic - autoimmune conditions - TB - cancer - injury to pericardium
72
Triad of cardiac tamponade
**Beck’s triad** - Raised JVP - Muffled heart sounds - Hypotension
73
Management of cardiac tamponade
Urgent pericardiocentesis
74
Adverse effects of nicorandil
Headaches Flushing Skin,mucosal + eye ulceration *e.g. GI ulcers*

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