deck_862050

Question 1

Name three organs/systems other CVS which can cause chest pain

Answer 1

Lungs and pleura GI systemChest wall

Question 2

What can be used to distinguish between different types of pain?

Answer 2

Character and type of pain, other special symptoms.

Question 3

What conditions of lungs and pleura cause chest pain? (3)

Answer 3

PneumoniaPulmonary EmbolismPneumothorax

Question 4

What conditions of the GI system cause chest pain?

Answer 4

Oesophagus – RefluxPeptic ulcer diseaseGall Bladder – Biliary colic, cholecystitis

Question 5

What conditions of the chest wall cause chest pain?

Answer 5

Ribs – fractures, bone metastasesMusclesSkin (herpes zoster) Costo-chondral joints

Question 6

What conditions of the CVS cause chest pain?

Answer 6

Myocardium – Angina, MIPericardium – PericarditisAorta – Aortic dissection

Question 7

What are the two types of risk factors for coronary atheroma?

Answer 7

ModifiableNon-modifiable

Question 8

Give three non-modifiable risk factors for coronary artheroma

Answer 8

Increasing AgeMale gender (females catch up after menopause)Family history

Question 9

Give seven modifiable risk factors for coronary atheroma

Answer 9

HyperlipidaemiaSmoking HypertensionDiabetes mellitus – Doubles IHD riskExerciseObesityStress

Question 10

What are the four main risk factors for coronary artheroma?

Answer 10

HyperlipidaemiaSmokingHypertensionDiabetes mellitus (doubles IHD)

Question 11

What type of pain can IHD cause?

Answer 11

Central, retrosternal or left sided

Question 12

Describe the course of the pain from IHD

Answer 12

Pain my radiate to shoulder and arms, with left side more common that the right- May radiate along the neck, jaw, epigastrium and back.

Question 13

Describe the character of the pain from IHD

Answer 13

Crushing, occasionally described as burning epigastric pain (inferior MI)

Question 14

How does pain from IHD vary?

Answer 14

In intensity, duration, onset and precipitation. Aggravating and relieving factors and associated symptoms

Question 15

How does pain from IHD get worse?

Answer 15

Stable angina –> Unstable angina –> MI

Question 16

Describe the structure of atheromas in stable angina

Answer 16

Atheromatous plaques with a necrotic centre and fibrous cap

Question 17

What is the effect of atheroma in IHD?

Answer 17

Occlude more and more of the lumen as they build up in coronary vessels. This leaves less space for passage of blood and ischaemia in myocardium

Question 18

What area is most at risk of ischaemia?

Answer 18

Subendocardial surface, myocardial wall pressure greatest

Question 19

How does coronary arteries increase O2 uptake?

Answer 19

Increase flow, via vasodilator metabolites (adenosine, K+, H+)Collateral circulationO2 uptake already maximum!

Question 20

What increases myocardial demand?

Answer 20

Heart rateWall tension - preload, afterloadContractility

Question 21

What does myocardial O2 supply depend on?

Answer 21

Coronary blood flow- perfusion pressure- coronary artery resistance O2 carrying capacity

Question 22

What is the usual presentation of a STEMI?

Answer 22

• Chest pain not relieved by GTN - N&V- May be painless +/- atypical - Acute pulmonary oedema, SOB, syncope, cardiogenic shock

Question 23

What are four ECG findings you will see in STEMI?

Answer 23

• ST elevation (see above)- New LBBB - +/- T wave inersion- Pathological Q waves

Question 24

Give 4 steps in initial management of STEMI

Answer 24

• Airway, Breathing, Circulation- IV access - 12-lead ECG- MONA

Question 25

What is MONA?

Answer 25

o Morphine (2.5 – 10mg + antiemetic)o Oxygeno Nitrates (GTN spray 2 puffs sublingually) o Aspirin (300mg chewed)

Question 26

What are three investigations you should do in STEMI?

Answer 26

- Bloods o FBC, U&E, LFTs, glucose, lipids, CK, Troponin I - Portable CXR - ECG

Question 27

What are two main treatments in STEMI?

Answer 27

Thrombolysis or PCI

Question 28

When is PCI used?

Answer 28

 PCI is the gold standard for acute coronary syndrome and should only be used if primary PCI programme available within 120 minutes of first medical contact Indications are the same as thrombolysis

Question 29

What are the ECG changes which indicate thrombolysis or PCI?

Answer 29

• ST elevation >1mm in 2+consecutive leads• ST elevation >2mm in 2+consecutive leads• New onset LBBB

Question 30

Give four contraindication for thrombolysis

Answer 30

• Haemorrhagic sroke or ischaemic stroke

Question 31

What do you give along with PCI or thrombolysis?

Answer 31

B blockerACE inhibitor Clopidogrel

Question 32

What complications can you develop as a result of a STEMI?

Answer 32

SPREADS – Sudden DeathP – Pump failure/pericarditisR – Rupture papillary muscle or septumE – EmbolismA – Aneurysm/arrhytmias D – Dresslers syndrome ( pleuritic chest pain, pericarditis and low grade fever which develops post-MI and is thought to be immune mediated.

Question 33

What do you prescribe on discharge post-MI

Answer 33

Aspirin, clopidogrel, ACE inhibitor, B blocker, Statin, Risk factor modification, 1 month off work.

Question 34

What are the two main ECG changes in an NSTEMI?

Answer 34

1) T wave inversion 2) ST depression

Question 35

How do you differentiate between STEMI and NSTEMI?

Answer 35

NSTEMI will have a positive troponin I and unstable angina will be negative.

Question 36

What are the management steps for an NSTEMI/

Answer 36

1) Analgesia a. Morphine2) Anti-ischaemica. Nitrates b. ACE inhibitor c. B blockersd. Calcium channel antagonistse. Statins3) Anti-platelets a. Aspirinb. Clopidogrel 4) Anti-thrombotic a. LMWH

Question 37

When is PCI considered in an NSTEMI?

Answer 37

PCI can be considered if Troponin is persistently raised, the angina persists despite best medical therapy or there are features of- Heart failure- Poor LV function- Haemodynamic instability - PCI

Question 38

What is the SA Node suppliedby?

Answer 38

RCA

Question 39

What is the AV node supplied by?

Answer 39

RCA

Question 40

What is the bundle of HIS supplied by?

Answer 40

LAD

Question 41

WHAT is the RBBB supplied by?

Answer 41

Proximal portion by LADDistal Portion by RCA

Question 42

What is the LBBB suppied by?

Answer 42

LADLAD and PDA