Flashcards in Session 10 - Ischaemic Heart Disease and Chest Pain (1) Deck (42):
Name three organs/systems other CVS which can cause chest pain
Lungs and pleura
What can be used to distinguish between different types of pain?
Character and type of pain, other special symptoms.
What conditions of lungs and pleura cause chest pain? (3)
What conditions of the GI system cause chest pain?
Oesophagus – Reflux
Peptic ulcer disease
Gall Bladder – Biliary colic, cholecystitis
What conditions of the chest wall cause chest pain?
Ribs – fractures, bone metastases
Skin (herpes zoster)
What conditions of the CVS cause chest pain?
Myocardium – Angina, MI
Pericardium – Pericarditis
Aorta – Aortic dissection
What are the two types of risk factors for coronary atheroma?
Give three non-modifiable risk factors for coronary artheroma
Male gender (females catch up after menopause)
Give seven modifiable risk factors for coronary atheroma
Diabetes mellitus – Doubles IHD risk
What are the four main risk factors for coronary artheroma?
Diabetes mellitus (doubles IHD)
What type of pain can IHD cause?
Central, retrosternal or left sided
Describe the course of the pain from IHD
Pain my radiate to shoulder and arms, with left side more common that the right
- May radiate along the neck, jaw, epigastrium and back.
Describe the character of the pain from IHD
Crushing, occasionally described as burning epigastric pain (inferior MI)
How does pain from IHD vary?
In intensity, duration, onset and precipitation.
Aggravating and relieving factors and associated symptoms
How does pain from IHD get worse?
Stable angina --> Unstable angina --> MI
Describe the structure of atheromas in stable angina
Atheromatous plaques with a necrotic centre and fibrous cap
What is the effect of atheroma in IHD?
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
What area is most at risk of ischaemia?
Subendocardial surface, myocardial wall pressure greatest
How does coronary arteries increase O2 uptake?
Increase flow, via vasodilator metabolites (adenosine, K+, H+)
O2 uptake already maximum!
What increases myocardial demand?
Wall tension - preload, afterload
What does myocardial O2 supply depend on?
Coronary blood flow
- perfusion pressure
- coronary artery resistance
O2 carrying capacity
What is the usual presentation of a STEMI?
- Chest pain not relieved by GTN
- May be painless +/- atypical
- Acute pulmonary oedema, SOB, syncope, cardiogenic shock
What are four ECG findings you will see in STEMI?
- ST elevation (see above)
- New LBBB
- +/- T wave inersion
- Pathological Q waves
Give 4 steps in initial management of STEMI
- Airway, Breathing, Circulation
- IV access
- 12-lead ECG
What is MONA?
o Morphine (2.5 – 10mg + antiemetic)
o Nitrates (GTN spray 2 puffs sublingually)
o Aspirin (300mg chewed)
What are three investigations you should do in STEMI?
o FBC, U&E, LFTs, glucose, lipids, CK, Troponin I
- Portable CXR
What are two main treatments in STEMI?
Thrombolysis or PCI
When is PCI used?
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
What are the ECG changes which indicate thrombolysis or PCI?
• ST elevation >1mm in 2+consecutive leads
• ST elevation >2mm in 2+consecutive leads
• New onset LBBB
Give four contraindication for thrombolysis
• Haemorrhagic sroke or ischaemic stroke
What do you give along with PCI or thrombolysis?
What complications can you develop as a result of a STEMI?
S – Sudden Death
P – Pump failure/pericarditis
R – Rupture papillary muscle or septum
E – Embolism
A – Aneurysm/arrhytmias
D – Dresslers syndrome ( pleuritic chest pain, pericarditis and low grade fever which develops post-MI and is thought to be immune mediated.
What do you prescribe on discharge post-MI
Aspirin, clopidogrel, ACE inhibitor, B blocker, Statin, Risk factor modification, 1 month off work.
What are the two main ECG changes in an NSTEMI?
1) T wave inversion
2) ST depression
How do you differentiate between STEMI and NSTEMI?
NSTEMI will have a positive troponin I and unstable angina will be negative.
What are the management steps for an NSTEMI/
b. ACE inhibitor
c. B blockers
d. Calcium channel antagonists
When is PCI considered in an NSTEMI?
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
What is the SA Node suppliedby?
What is the AV node supplied by?
What is the bundle of HIS supplied by?
WHAT is the RBBB supplied by?
Proximal portion by LAD
Distal Portion by RCA