Cardiac DDx

Question 1

What are the life-threatening causes of chest pain? (6)

Answer 1

• ACS
• Dissection
• Tamponade
• PE
• Tension pneumothorax
• Mediastinitis (e.g. oesophageal rupture)

Question 2

What are the broad categories of chest pain? (5)

Answer 2

• Cardiac – ACS/angina/dissection/inflammation/tamponade
• Respiratory – pleuritis/PNA/PE/COAD/lung Ca
• Gastrointestinal – GORD, oesophageal spasm, rupture (Boerhaave’s)
• MSK – rib contusion, #, costochondritis
• Psychitric – panic attack

Question 3

What are the cardiac causes of angina other than Coronary Artery Disease (and hypovolaemia)? (4)

Answer 3

• Worsening valve disease → angina
• Arrythmia → angina due to impaired coronary blood flow
• Pericardial effusion → angina due to impaired blood flow
• Inflammatory: pericarditis, myocarditis, endocarditis

Question 4

What BNP values are suggestive of HF?

Answer 4

• >100 highly sensitive for acute HF
• <50 → highly unlikely to be hF

Question 5

Collapse differentials (9)?

Answer 5

SOAR MAN Sleeps in Trauma

Syncope

• Structural cardiopulmonary disease
• Orthostatic syncope (can be delayed to 5 minutes) - inc. dehydration, bleeding, Addison’s
• Arrythmia
• Reflex syncope (cough, micturition)

Non syncopal

• Metabolic (hypoglycaemia, ETOH)
• Autonomic hypotention (Parkinson’s, DM, MSA) & Anaemia
  
  • Also Atypical – psychiatric (pseudosyncope or pseudoseizures)
• Neurological – seizures, epilepsy & vertigo. Stroke (vertebrobasilar insufficiency - rare)
• Sleep disorders – narcolepsy & cataplexy
• Traumatic brain injury

Question 6

Collapse history?

Answer 6

• Number, frequency and duration (days/wks/mths) of episodes
• Onset – with or without warning – if so for how long
• Classic reflex syncope = nausea, diaphoresis, feeling hot or cold
• No warning – more likely to be cardiac

•Position

• Supine to erect → orthostatic (can be several minutes of standing)
• Occurring in supine → more worrisome for arrythmia

•Provocating factors

• During vs. immediately after exercise: during exercise more serious (e.g. exercise triggered tachyarrythmia), if immediately after more benign (reflex syncope)
• Urination, defecation, coughing or swallowing → situational syncope
• Warm & crowded place
• Stress, fear, intense pain
• Abrupt neck movements → carotid sinus hypersensitivity
• Pre-dromal symptoms: palpitations, SOB, CP, visual changes
• Post-dromal symptoms: confusion, incontinennce
• Family history

Question 7

What is your approach to investigation in patient with collapse?

Answer 7

• Clinical: collaterals, postural BP, BSLs & ECG, meds recently started
• Bloods: anaemia, metabolic acidosis/alkalosis
• Imaging:
• ECHO – looking for structural heart disease (e.g. AS, HOCM, pHTN)
• Carotid doppler - ?ICA stenosis (can worsen postural hypo)

•CTPA

• Neurologic if symptoms consistent –CTB, MRIB
• Special tests:
• Holter, telemetry or loop recorder – NSVT, pAF…etc
• Consider EST – if IHD is suspected
• Consider EEG

Question 8

If TTE, holter and ECG are completely normal and hx sounds reflex/vasovagal – what is the useful confirmatory test?

Answer 8

• Tilt-table testing – principally directed at unmasking susceptibility to vasovagal syncope
• Carotid sinus massage – exclusively directed to carotid sinus hypersensitivity

Question 9

What are the typical findings in tilt-table testing for following conditions?

• Reflex syncope
• Orthostatic hypotension
• Pseudosyncope

Answer 9

• Reflex syncope: significant fall in BP with TLOC or inability to maintain posture (if without TLOC – suggestive of Reflex syncope)
• Orthostatic hypotension: progressive ↓ in BP with/without symptoms
• Pseudosyncope: TLOC or inability to maintain posture in absence of BP drop