chest pain

chest pain

Ischemic heart disease
1. MI
  1. NSTEMI
    1. Incomplete occlusion (varies in intens, not usu as bad as STEMI
  2. STEMI
    1. Complete occlusion of vssl (usually atheroma -> thrombus, ruptures, maybe embolus)
    2. diag: Hx, ECG,raised troponin I and T, CK-MB
    3. symps/signs
      1. severe chest pain >20min
      2. doesn't respond to GTN
      3. may rad to L arm/jaw
      4. autonomic symps: sweaty, clammy, pale
      5. thready pulse w/signif hypotens, brady or tachycardia
    4. investigs:
      1. ECG
        first mins: ST up
        first hrs: T waves invert, R wave voltage down, Q waves devel
        days: ST to normal
        T wave may return to upright, q wave remains
      2. blood samples
        troponin I or T; CK-MB
        FBC, serum electrolytes (U+ E's), glucose, lipid profile
      3. echo (transthoracic)
        wall motion abnorms (detectable early)
    5. treatment
      1. A+ E: chew aspirin, clopidogrel, GTNx2, oxygen, opiate, B-blocker
      2. PCI (w/in 90mins if avail)
      3. Fibrinolysis (first 6-12 hrs)
      4. Post MI: lifestyle modific, Aspirin, B-blocker, ACE inhibitor, Statin, Clopidogrel, Aldosterone antag
  3. myocytes die due to ischemia
  4. diag: Hx, ECG, biochem markers (troponin 1 and T, CK-MB)
  5. Clin Present: new onset/at rest chest pain or deteriorating angina
  6. Exam: detect alt diags (aortic dissect, PE, peptic ulcer), detect adverse clin signs (hypotens, basal crackles, 4th heart sound, heart murmurs)
  7. treatment
    1. aspririn, antithrombins (eg warfarin), B-blockers, statins, ACE inhibitors,
    2. if hi risk: stenting, CABG
    3. Risk factor modif
  8. Investigs
    1. ECG: ST depression and T wave inversion highly suggestive of ACS
    2. Troponin, CK-MB
    3. If high risk for MI or death- urgent coronary angiography
2. Angina
  1. pain characteristics
    1. heavy tight gripping
    2. central/retrosternal
    3. may rad to jaw/arms
    4. mild to severe
    5. maybe breathlesss
  2. classical triggers
    1. exercise
    2. cold
    3. after meals
    4. emotion
  3. exam
    1. usually no abnorm findings
    2. exclude aortic stenosis
    3. BP (for coexist HBP)
    4. look for signs of anemia, thyrotoxicosis, hyperlipidemia
  4. investigations
    1. exercise ECG (ST depresss of >1mm suggests myocard ischemia)
    2. echo (for ventric func or wall abnorms)
    3. CT coronary angio- helps diag CAD, exclude PE
  5. treatment
    1. Correct risk factors
    2. Medical: prophylaxis aspirin, statin/fibrate; symptomatic GTN; prophylax choose 1+of: B-blockers, Longact nitrates, CCB, (also verpamil or diltiaszem but not w/BBlockers)
    3. Surgical: revascularization
      1. PCI
      2. CABG
3. Causes: mech obstruct (CAD-atheroma, throbmosis/embolus, spasm, stensosis) OR decreased flow (anemia, hypotension, etc)
  1. CAD is biggest single cause of death in UK. inflam -> lesions -> fatty deposits -> complicated plaques -> thrombi
    1. CAD RISK FACTORS:
      1. fixed: age, male, FH, deletion in ACE gene
      2. changeable: hyperlipidemia, high alcohol, smoke, hypertension, DM, exercise, blood coag, personality, obesity, gout, drugs (COC, nucleoside anaolgues, COX-2 inhibitors, rosiglitazone) homocysteinemai, C-RP
PE
1. if large: sudden, severe. dypnea, haemoptysis, syncope, previous DVT. maybe no symps
Pneumonia
1. pleuritic pain (sharp, stabbing). assoc breathless. maybe hyperres, decreased breathsounds. do CXR
GORD
1. burning, may rad upward. worse supine, maybe after meals. recent weight gain?
Anxiety
1. panic attacks. ask ice (reassure not heart attack)
2. assoc feats: breathless 'inabil to get enough air,' tingling around mouth, onset of symps coincides w/stress
(others: aortic dissection, acute pericarditis, pneumothorax
1. dissection: ripping, maybe shoulder pain, severe, autonomic symps, ?shock
2. pericard: worse on insp/lying, eased by sit forward. constant, sharp stabbing. maybe rub on auscult
3. pneumothorax: unilat sudden onset pleuritic. w/breathless. take CXR
Aortic stenosis
1. causes: progressive calfic due to: congen, rheumatic fever, AGE
  1. pathophys: causes less LV empty, so LV press up + hypertrophy -> LV ischemia -> angina, arryth, LV fail
2. symp: presents LATE: angina, exercise induced syncope, dyspnea
3. for diff diag: check no obstruction to LV empty (eg hypertrophy)
4. signs: slow rising pulse, maybe systolic thrill, may feel 4th sound (dbl impulse), EJECTION SYSTOLIC MUMUR (crescendo decresenco- diamond shaped) (other signs: systolic ejeciton slick, soft 2nd HS, prominent 4th sound)
5. investig
  1. CXR: small heart, dilated asc aorta
  2. ECG: LV hypertrophy + L atrial delay
    1. strain pattern: depressed sT seg, T wave inversion in lleads orientated toward LV
  3. echocardiogram
    1. thickened, calcif + immobile, aortic valve cusps, maybe LV hypertroph
6. treatment
  1. if symptomatic: valve replace
Muscskel
1. worse on move? may respond to NSAIDS

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