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  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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,
  9. 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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