CVS - Chest Pain

Question 1

What are the three main parts to making a diagnosis in someone who presents with chest pain?

Answer 1

• history
• clinical examinations
• investigations

Question 2

What are the possible respiratory causes of chest pain?

Answer 2

• PNEUMONIA: would present with pain off to one side, would also have temperature, cough and breathlessness
• PULMONARY EMBOLISM: sharp chest pain, well localised, worse when breathing in/coughing

Question 3

What could be a possible upper gastrointestinal cause of chest pain?

Answer 3

• ACID REFLUX: burning pain seems to ‘run up front of chest’, certain foods and lying flat make it worse

Question 4

What would be some possible cardiac causes of chest pain?

Answer 4

• ISCHAEMIC (dull pain, retrosternal, not well localised - may radiate to jaw, neck and shoulders and is worse with exertion)
• PERICARDITIS (inflammation of pericardial sac causes sharp, retrosternal pain which is eased by sitting up and leaning forward)

Question 5

Give some musculoskeletal causes of chest pain

Answer 5

• RIB FRACTURE
• CHOSTOCHONDRITIS (sharp, well localised, worse when pressed/tender, worse with coughing/inspiration and movement of the chest wall)

Question 6

What is the difference between pleural/pericardial pain vs cardiac ischaemic chest pain?

Answer 6

• pain from the heart/lungs is described as ‘visceral’ pain, and is dull, poorly localised and worsened with exertion. It is controlled by the autonomic nervous system.
• pain from the pleural/pericardial sac is decribed as ‘somatic’ pain. It is sharp, well localised and worse with inspiration, coughing or positional movement

Question 7

What is pericarditis?

Answer 7

Inflammation of the pericardium. Occurs most often in men/adults (not children). Often secondary to viral illness

Question 8

What would be the presenting compliant in someone with pericarditis?

Answer 8

• retrosternal pain
• sharp, localised to front of chest
• aggravated with inspiration, coughing, lying flat
• eased by sitting up/leaning forward
• may hear ‘pericardial rub’ on auscultation

Question 9

What would be different about the ECG of someone with pericarditis?

Answer 9

Widespread saddle shaped ST elevation

Question 10

Define cardiac (ischaemic) chest pain

Answer 10

Pain secondary to pathology involving the heart.

Question 11

Give some modifiable risk factors for atherosclerosis/ischaemic heart disease

Answer 11

• smoking
• hypertension
• hypercholesterolaemia
• diabetes
• obesity
• sedentary lifestyle

Question 12

Give some non-modifiable risk factors for atherosclerosis/ischaemic heart disease

Answer 12

• advanced age
• family history
• being male

Question 13

Why does stable angina only cause symptoms sometimes?

Answer 13

Heart tissue ischaemia occurs only when metabolic demands of cardiac muscle are greater than what can be delivered via coronary arteries. When at rest, the patient is fine. When they start to exercise, the body needs more blood so ischaemia and chest pain occur

Question 14

What are the typical symptoms of stable angina?

Answer 14

• dull retrosternal chest pain triggered by exertion and relived completely by rest
• no pain at rest
• pain may radiate to neck and shoulders
• won’t feel particularly unwell
• GTN spray relieves pain

Question 15

What is included within the category of ‘acute coronary syndrome’?

Answer 15

• unstable angina
• myocardial infarction
• NSTEMI
• STEMI

Question 16

What are acute coronary syndromes?

Answer 16

Acute myocardial ischaemia caused by atherosclerotic coronary artery disease - atheromatous plaques rupture leading to platelet aggregation and formation of thrombus causing an acute increased occlusion leading to ischaemia

Question 17

Why are cardiac enzymes released in NSTEMI and STEMI but not in unstable angina?

Answer 17

• unstable angina only leads to heart tissue ischaemia, as the lumen is mostly clear
• NSTEMI and STEMI have partially and fully occluded lumens respectively, so heart tissue death (infarction) occurs and cardiac enzymes leak from necrosis cardiac muscle cells.

Question 18

What is the difference in symptoms between unstable and stable angina?

Answer 18

They are very similar, but in unstable angina the pain will occur at rest, may be more intense and may last longer

Question 19

What are the typical symptoms of a myocardial infarction?

Answer 19

• dull retrosternal chest pain, and crushing/heavy feeling
• pain is severe and may radiate to neck/shoulders even at rest
• patient looks very unwell
• sweating, pallor, feel nauseous
• pain ongoing for more than 15 minutes
• nothing makes it better

Question 20

Which diagnostic tests should be carried out in cases of suspected acute coronary syndrome?

Answer 20

• ECG (changes suggest current ischaemia/infarct)
• blood tests (troponin presence indicates cardiac myocyte death)
• other investigations to exclude other potential diagnoses and identify complications

Question 21

Which ECG changes will be seen in a STEMI?

Answer 21

• ST segment elevation
• hyperacute T waves

Localisation of these changes helps to determine anatomical site

Question 22

What ECG changes will be seen in unstable angina and NSTEMI?

Answer 22

• ST segment depression

- T wave flattening/inversion