Chapter 013. Chest Discomfort (Part 2) pdf

Chest Discomfort Part 2 Angina Pectoris See also Chap.. 237 The chest discomfort of myocardial ischemia is a visceral discomfort that is usually described as a heaviness, pressure, or

Chapter 013 Chest Discomfort

(Part 2)

Angina Pectoris

(See also Chap 237) The chest discomfort of myocardial ischemia is a visceral discomfort that is usually described as a heaviness, pressure, or squeezing (Table 13-2) Other common adjectives for anginal pain are burning and aching Some patients deny any "pain" but may admit to dyspnea or a vague sense of anxiety The word "sharp" is sometimes used by patients to describe intensity rather than quality

Table 13-2 Typical Clinical Features of Major Causes of Acute Chest Discomfort

Condition Durati

on

Qualit

y

Location Associat

ed Features

Angina More

than 2 and less than 10 min

Pressu

re, tightness, squeezing, heaviness, burning

Retroster nal, often with radiation to or isolated

discomfort in neck, jaw, shoulders, or arms—

frequently on left

Precipita ted by exertion, exposure to cold,

psychologic stress

S4 gallop

or mitral regurgitation murmur during pain

Unstable

angina

10–20 min

Simila

r to angina but often more severe

Similar to angina

Similar

to angina, but occurs with low levels of exertion or even at rest

Acute Variabl Simila Similar to Unreliev

myocardial

infarction

e; often more than 30 min

r to angina but often more severe

angina ed by

nitroglycerin

May be associated with evidence of heart failure or arrhythmia

Aortic

stenosis

Recurr ent episodes

as described for angina

As described for angina

As described for angina

Late-peaking systolic murmur

radiating to carotid arteries

Pericarditis Hours

to days; may

be episodic

Sharp Retroster

nal or toward cardiac apex;

may radiate to left shoulder

May be relieved by sitting up and leaning forward

Pericardi

al friction rub

Aortic

dissection

Abrupt onset of unrelenting pain

Tearin

g or ripping sensation;

knifelike

Anterior chest, often radiating to back, between shoulder blades

Associat

ed with hypertension and/or

underlying connective tissue disorder, e.g., Marfan syndrome

Murmur

of aortic insufficiency, pericardial rub, pericardial tamponade, or loss of peripheral pulses

Pulmonary Abrupt Pleurit Often Dyspnea

embolism onset; several

minutes to a few hours

ic lateral, on the

side of the embolism

, tachypnea, tachycardia, and

hypotension

Pulmonary

hypertension

Variabl

e

Pressu

re

Substerna

l

Dyspnea , signs of increased

venous pressure including

edema and jugular venous distention

Pneumonia

or pleuritis

Variabl

e

Pleurit

ic

Unilateral , often localized

Dyspnea , cough, fever, rales,

occasional rub

Spontaneous

pneumothorax

Sudden onset; several

Pleurit

ic

Lateral to side of

Dyspnea , decreased

hours pneumothorax breath sounds

on side of pneumothorax

Esophageal

reflux

10–60 min

Burni

ng

Substerna

l, epigastric

Worsene

d by postprandial recumbency

Relieved

by antacids

Esophageal

spasm

2–30 min

Pressu

re, tightness, burning

Retroster nal

Can closely mimic angina

Peptic ulcer Prolon

ged

Burni

ng

Epigastri

c, substernal

Relieved with food or antacids

Gallbladder Prolon Burni Epigastri

c, right upper

May

disease ged ng, pressure quadrant,

substernal

follow meal

Musculoskel

etal disease

Variabl

e

Achin

g

Variable Aggravat

ed by movement

May be reproduced by localized

pressure on examination

Herpes

zoster

Variabl

e

Sharp

or burning

Dermato mal distribution

Vesicula

r rash in area of discomfort

Emotional

and psychiatric

conditions

Variabl e; may be fleeting

Variab

le

Variable;

may be retrosternal

Situation

al factors may precipitate symptoms

Anxiety

or depression often detectable with careful history

The location of angina pectoris is usually retrosternal; most patients do not

localize the pain to any small area The discomfort may radiate to the neck, jaw, teeth, arms, or shoulders, reflecting the common origin in the posterior horn of the spinal cord of sensory neurons supplying the heart and these areas Some patients present with aching in sites of radiated pain as their only symptoms of ischemia Occasional patients report epigastric distress with ischemic episodes Less common is radiation to below the umbilicus or to the back

Stable angina pectoris usually develops gradually with exertion, emotional excitement, or after heavy meals Rest or treatment with sublingual nitroglycerin typically leads to relief within several minutes In contrast, pain that is fleeting (lasting only a few seconds) is rarely ischemic in origin Similarly, pain that lasts for several hours is unlikely to represent angina, particularly if the patient's electrocardiogram (ECG) does not show evidence of ischemia

Anginal episodes can be precipitated by any physiologic or psychological stress that induces tachycardia Most myocardial perfusion occurs during diastole,

when there is minimal pressure opposing coronary artery flow from within the left ventricle Since tachycardia decreases the percentage of the time in which the heart is in diastole, it decreases myocardial perfusion