Flashcards in DPD 1 - Chest pain Deck (55)
A 60 y/o man presents w/ tight, chest pain for 4 hrs. He has nausea, sweating + breathlessness. PMHx: HTN for which he takes amlodipine. What is the most likely Dx?
4. Aortic dissection
Breathlessness may be due to HF or arrhythmias
Nausea + sweating are associated w/ cardiac disease/ischaemia due to stimulation of vagal afferents
What are the Ix for chest pain? (x3)
1. ECG: Is it STEMI? (If yes, aspirin/clopidogrel --> PCI (Cathlab) + Angiogram/angioplasty). Is it NSTEMI? (If yes, aspirin/clopidogrel/fondaparinux)
2. Troponin: +ve (Coronary angiography, PCI); -ve (ETT); troponin traditionally done at 12h but can say 6h
3. Echocardiography: identifies any regional wall motion abnormality (due to blockage of one of the coronaries/ventricular dysfunction)
REMEMBER: ECG, Troponin, Echo
What are the DDx of chest pain? (x4 broad categories)
What are the cardiac causes of chest pain?
1. IHD - Angina pectoris; ACS (MI) - tight chest pain w/ nausea + sweating. Rx: Diabetes, smoking, HTN
2. Aortic dissection: sudden onset chest pain radiating to back. Rx: HTN. O/E: Difference in BP between 2 arms + early diastolic murmur (aortic regurgitation)
3. Pericarditis: pleuritic chest pain - sharp + worse on inspiration. Better when leaning forward. Preceding flu-like illness
What are the respiratory causes of chest pain?
1. Pulmonary Embolism: Acute onset SOB, swollen leg, pleuritic, haemoptysis. Rx: Immobility, Malignancy, FHx, recent fracture
2. Pneumonia: Cough, Fever, Sputum
3. Pneumothorax: Pleuritic chest pain, acute onset
What are the GI causes of chest pain?
What is the musculoskeletal cause of chest pain?
Costochondritis (Tietze's syndrome: more localized over sternum) - musculoskeletal tenderness
A 60 y/o man presents w/ tight, chest pain for 4 hrs. He has nausea, sweating + breathlessness. PMHx: HTN for which he takes amlodipine. O/E: Temp 37.0, HS: S1+S2; No difference in BP in both arms; clear chest; abdo: SNT. What is the next most appropriate Ix?
What coronary artery is affected in an anterior MI + which ECG leads are affected?
Left Anterior Descending (LAD)
V1 - V4
What coronary artery is affected in an inferior MI + which ECG leads are affected?
Right coronary artery
II, III, aVF
What coronary artery is affected in a lateral MI + which ECG leads are affected?
Left circumflex artery
V5, V6, I, aVL
What coronary artery is affected in a posterior MI + which ECG leads are affected?
Posterior descending (usually a branch of right coronary artery)
Tall R wave + ST depression in V1 - V3
Which cardiac enzyme is most sensitive for MI?
Measured at 3 hr & observe increments - measure serial troponin
Stays elevated for up to 2-3 days afterwards
A 30 y/o man comes in w/ collapse. Before: no warning. During: no tongue biting. After: Not confused. FHx: Brother died at a young age. O/E: HS: S1+S2+0; no difference in lying and standing BP, Vesicular breath sounds, Abdo SNT, CNI - XII NAD, Normal I, T, P, R, C, S, Gait. What is the most likely cause of his collapse?
1. Aortic stenosis
2. Pulmonary embolism
3. Postural hypotension
Tacharrythmia e.g. VT due to FHx which indicates cardiac arrhythmia.
Not PE because there is no outflow obstruction on right side + no risk factors
What are the causes of collapse?
1. Cardiac (VAOP): (a) Vasovagal: increase vagal discharge - bradycardia; triggers: hot weather, standing for a long time. Buzzwords: Pale, sweaty before collapse, no confusion. (b) Arrhythmia: Tachycardia, bradycardia. (c) Outflow obstruction: Left: aortic stenosis, HOCM (Thickening of septum of heart) or Right: PE (d) Postural hypotension
2. Neurological: Seizure - aura, stereotypical movements, biting tongue, incontinence, post-ictal confusion
3. Hypoglycaemia: DNEFG(Do not ever forget glucose), Check CBG
What is long QT syndrome + what are the causes of it + what does it predispose to?
Abnormal ventricular repolarisation
Causes: Congenital: Long QT syndrome e.g. mutations in K+ channel & FHx. Acquired: Hypokalaemia/hypomagnesia or drugs.
Predisposes to ventricular tachycardia
A 45 y/o man presents w/ fever + malaise. He is an IVDU. O/E: Temp: 38; raised JVP to earlobes; HS: S1 + S2 + PSM (louder on inspiration). What is the cause of his raised JVP?
1. Constrictive pericarditis
2. Congestive cardiac failure
3. Aortic regurgitation
4. Mitral regurgitation
5. Tricuspid regurgitation
IVDU are prone to infective endocarditis which affects right heart and can cause tricuspid regurgitation. JVP increased to earlobes also suggests TR. PSM indicates TR or MR or ventricular septal defect however right sided murmurs are louder on inspiration (tricuspid or pulmonary) and left heart murmurs are louder on expiration (aortic or mitral)
What are the DDx of increased JVP? (x3)
1. Right heart failure: secondary to (a) L heart failure (= CHF) or (b) pulmonary HTN (PE, COPD). In COPD, chronic hypoxia --> chronic vasoconstriction --> pulmonary HTN
2. Tricuspid regurgitation: damage to valve leaflets (infective endocarditis/IVDU) or right ventricle dilatation of the valve ring (valve root enlarges) so leaks through valve
3. Constrictive pericarditis: thickening/calcification of pericarditis: caused by infection (TB), inflammation (connective tissue disease e.g. Lupus, sarcoid), malignancy
What are the DDx of systolic murmurs?
1. Aortic stenosis
2. Mitral regurgitation
3. Tricuspid regurgitation
4. Ventricular septal defect
What are the clinical features of aortic stenosis?
Loudest in aortic area
Radiates to carotids
Assoc. w/ slow-rising pulse
What are the clinical features of mitral regurgitation?
Loudest in mitral area
Radiates to axilla
Assoc. w/ displaced apex beat
Loudest on expiration
What are the clinical features of tricuspid regurgitation?
Louder in tricuspid area: left lower sternal edge (assoc. w/ high JVP)
Louder on inspiration
What are the clinical features of ventricular septal defect?
Loudest at the left sternal border accompanied by parasternal thrill
A 65 y/o man presents with SOB, palpitations. PMHx: HTN. DHx: Bendroflumethiazide. O/E: Temp: 38; HR: 160, irregular; BP: 110/80; Dull percussion note + coarse crackles L base (consolidation). What would you expect to see on his ECG?
2. Sinus tachycardia
What does an ECG tell you? (x3)
Ischaemic changes: ST elevation, depression
Electrical abnormalities: prolonged QT interval, tachycardia
Structural abnormalities (Deep S in V1, deep R in V6 = LVH =HTN)
A 65 y/o man presents with SOB, palpitations. PMHx: HTN. DHx: Bendroflumethiazide. O/E: Temp: 38; HR: 160, irregular; BP: 110/80; Dull percussion note + coarse crackles L base (consolidation). What is the most likely diagnosis?
What are the characteristics + causes of sinus tachycardia?
Characteristics: increased HR, all components present (PQRST) P waves present
Causes: sepsis, hypovolaemia, endocrine (thyrotoxicosis, phaechromocytoma)
What are the characteristics + causes + Tx of supraventricular tachycardia?
Characteristics: Fast, regular; narrow complex (< 3 small squares); no P wave before QRS
Cause: Re-entry circuit
Tx: Is pt haemodynamically stable? Yes - Vagal manouvres. No - DC cardioversion. If vagal manouvres don't work IV adenosine 6 mg (slow conduction through AV node) --> IV adenosine 12 mg --> IV adenosine 12 mg --> IV BB, IV amiodarone
What are the two types of SVT?
1. AVNRT: Re-entry circuit at AV node (has 2 anatomical pathways). No p wave as depolarisation from AVN not SAN. Normal ECG after resolved.
2. AVRT: Re-entry circuit via Bundle of Kent - short PR interval (P wave present) + delta wave (slurred upstroke) when not tachycardic. Tx: radiofrequency catheter ablation to destroy accessory pathway