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  1. Chapter 013. Chest Discomfort (Part 3) Unstable Angina and Myocardial Infarction (See also Chaps. 238 and 239) Patients with these acute ischemic syndromes usually complain of symptoms similar in quality to angina pectoris, but more prolonged and severe. The onset of these syndromes may occur with the patient at rest, or awakened from sleep, and sublingual nitroglycerin may lead to transient or no relief. Accompanying symptoms may include diaphoresis, dyspnea, nausea, and light-headedness. The physical examination may be completely normal in patients with chest discomfort due to ischemic heart disease. Careful auscultation during ischemic episodes may reveal a third or fourth heart sound, reflecting myocardial systolic or diastolic dysfunction. A transient murmur of mitral regurgitation suggests ischemic papillary muscle dysfunction. Severe episodes of ischemia can lead to pulmonary congestion and even pulmonary edema.
  2. Other Cardiac Causes Myocardial ischemia caused by hypertrophic cardiomyopathy or aortic stenosis leads to angina pectoris similar to that caused by coronary atherosclerosis. In such cases, a loud systolic murmur or other findings usually suggest that abnormalities other than coronary atherosclerosis may be contributing to the patient's symptoms. Some patients with chest pain and normal coronary angiograms have functional abnormalities of the coronary circulation, ranging from coronary spasm visible on coronary angiography to abnormal vasodilator responses and heightened vasoconstrictor responses. The term "cardiac syndrome X" is used to describe patients with angina-like chest pain and ischemic-appearing ST-segment depression during stress despite normal coronary arteriograms. Some data indicate that many such patients have limited changes in coronary flow in response to pacing stress or coronary vasodilators. Despite the possibility that chest pain may be due to myocardial ischemia in such patients, their prognosis is excellent. Pericarditis (See also Chap. 232) The pain in pericarditis is believed to be due to inflammation of the adjacent parietal pleura, since most of the pericardium is believed to be insensitive to pain. Thus, infectious pericarditis, which usually involves adjoining pleural surfaces, tends to be associated with pain, while
  3. conditions that cause only local inflammation (e.g., myocardial infarction or uremia) and cardiac tamponade tend to result in mild or no chest pain. The adjacent parietal pleura receives its sensory supply from several sources, so the pain of pericarditis can be experienced in areas ranging from the shoulder and neck to the abdomen and back. Most typically, the pain is retrosternal and is aggravated by coughing, deep breaths, or changes in position— all of which lead to movements of pleural surfaces. The pain is often worse in the supine position and relieved by sitting upright and leaning forward. Less common is a steady aching discomfort that mimics acute myocardial infarction. Diseases of the Aorta (See also Chap. 242) Aortic dissection is a potentially catastrophic condition that is due to spread of a subintimal hematoma within the wall of the aorta. The hematoma may begin with a tear in the intima of the aorta or with rupture of the vasa vasorum within the aortic media. This syndrome can occur with trauma to the aorta, including motor vehicle accidents or medical procedures in which catheters or intraaortic balloon pumps damage the intima of the aorta. Nontraumatic aortic dissections are rare in the absence of hypertension and/or conditions associated with deterioration of the elastic or muscular components of the media within the aorta's wall. Cystic medial degeneration is a feature of several inherited connective tissue diseases, including Marfan and Ehlers-Danlos
  4. syndromes. About half of all aortic dissections in women under 40 years of age occur during pregnancy. Almost all patients with acute dissections present with severe chest pain, although some patients with chronic dissections are identified without associated symptoms. Unlike the pain of ischemic heart disease, symptoms of aortic dissection tend to reach peak severity immediately, often causing the patient to collapse from its intensity. The classic teaching is that the adjectives used to describe the pain reflect the process occurring within the wall of the aorta— "ripping" and "tearing"—but more recent data suggest that the most common presenting complaint is sudden onset of severe, sharp pain. The location often correlates with the site and extent of the dissection. Thus, dissections that begin in the ascending aorta and extend to the descending aorta tend to cause pain in the front of the chest that extends into the back, between the shoulder blades. Physical findings may also reflect extension of the aortic dissection that compromises flow into arteries branching off the aorta. Thus, loss of a pulse in one or both arms, cerebrovascular accident, or paraplegia can all be catastrophic consequences of aortic dissection. Hematomas that extend proximally and undermine the coronary arteries or aortic valve apparatus may lead to acute myocardial infarction or acute aortic insufficiency. Rupture of the hematoma into the pericardial space leads to pericardial tamponade.
  5. Another abnormality of the aorta that can cause chest pain is a thoracic aortic aneurysm. Aortic aneurysms are frequently asymptomatic but can cause chest pain and other symptoms by compressing adjacent structures. This pain tends to be steady, deep, and sometimes severe.
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