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- 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 Qualit Location Associat
on y ed Features
- Angina More Pressu Retroster Precipita
than 2 and less re, tightness, nal, often with ted by exertion,
than 10 min squeezing, radiation to or exposure to
heaviness, isolated cold,
burning discomfort in psychologic
neck, jaw, stress
shoulders, or
S4 gallop
arms—
or mitral
frequently on
regurgitation
left
murmur during
pain
Unstable 10–20 Simila Similar to Similar
angina min r to angina angina to angina, but
but often occurs with low
more severe levels of
exertion or
even at rest
Acute Variabl Simila Similar to Unreliev
- myocardial e; often more r to angina angina ed by
infarction than 30 min but often nitroglycerin
more severe
May be
associated with
evidence of
heart failure or
arrhythmia
Aortic Recurr As As Late-
stenosis ent episodes described for described for peaking systolic
as described angina angina murmur
for angina radiating to
carotid arteries
Pericarditis Hours Sharp Retroster May be
to days; may nal or toward relieved by
be episodic cardiac apex; sitting up and
may radiate to leaning forward
left shoulder
Pericardi
al friction rub
- Aortic Abrupt Tearin Anterior Associat
dissection onset of g or ripping chest, often ed with
unrelenting sensation; radiating to hypertension
pain knifelike back, between and/or
shoulder blades 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 ic lateral, on the , tachypnea,
minutes to a side of the tachycardia,
few hours embolism and
hypotension
Pulmonary Variabl Pressu Substerna Dyspnea
hypertension e re l , signs of
increased
venous pressure
including
edema and
jugular venous
distention
Pneumonia Variabl Pleurit Unilateral Dyspnea
or pleuritis e ic , often localized , cough, fever,
rales,
occasional rub
Spontaneous Sudden Pleurit Lateral to Dyspnea
pneumothorax onset; several ic side of , decreased
- hours pneumothorax breath sounds
on side of
pneumothorax
Esophageal 10–60 Burni Substerna Worsene
reflux min ng l, epigastric d by
postprandial
recumbency
Relieved
by antacids
Esophageal 2–30 Pressu Retroster Can
spasm min re, tightness, nal closely mimic
burning angina
Peptic ulcer Prolon Burni Epigastri Relieved
ged ng c, substernal with food or
antacids
Gallbladder Prolon Burni Epigastri May
c, right upper
- disease ged ng, pressure quadrant, follow meal
substernal
Musculoskel Variabl Achin Variable Aggravat
etal disease e g ed by
movement
May be
reproduced by
localized
pressure on
examination
Herpes Variabl Sharp Dermato Vesicula
zoster e or burning mal distribution r rash in area of
discomfort
Emotional Variabl Variab Variable; Situation
and psychiatric e; may be le may be al factors may
conditions fleeting retrosternal 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.
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