Chest Pain for Small Group August 25

Chest Pain for Small Group August 25 - Chest Pain Sumanth...

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Chest Pain Sumanth D. Prabhu, MD Chest pain is a commonly encountered symptom in both the emergency department and the outpatient clinic, resulting from a spectrum of etiologies from minor illness to life-threatening disease. Perhaps the most pressing determination is whether chest pain is due to acute cardiac ischemia or to nonischemic cardiovascular or noncardiac causes. Each of these categories encompasses etiologies that are potentially serious. In view of this, the initial evaluation, consisting of the history, physical examination, and electrocardiogram (ECG), is exceedingly important for determining the severity and acuity of the clinical presentation, and for guiding the proper selection of additional diagnostic and therapeutic modalities. Of these, the history remains the cornerstone of patient assessment. KEY TERMS 1 Angina pectoris Discomfort in the chest and/or adjacent areas (jaw, shoulder, back, arm), usually, but not always, due to myocardial ischemia Typical angina Substernal chest discomfort with the following features: Characteristic quality (described as “pressure,” “squeezing,” or “heaviness,” but almost never sharp or stabbing) and duration (typically minutes) Provoked by exertion or emotional stress Relieved by rest or nitroglycerin (within several minutes). Atypical angina Chest discomfort that meets 2 of the typical angina characteristics. Noncardiac chest pain Chest pain that meets 1 or none of the typical angina characteristics. Canadian Cardiovascular Society (CCS) Angina Classification System Clinical grading system based on degree of limitation of ordinary physical activity: Class I: No limitation Class II: Slight limitation Class III: Marked limitation Class IV: Angina occurs with any physical activity or at rest. Myocardial infarction (MI) Prolonged severe anginal discomfort associated with myocardial necrosis. Pleuritic chest pain Sharp chest pain that increases with inspiration or cough. Unstable angina (UA) Angina presenting as rest angina, severe new-onset angina (CCS class III or IV), or acceleration of previously diagnosed effort angina (to at least CCS class III). ETIOLOGY Chest pain may arise from cardiac, noncardiac, or psychogenic causes. Cardiovascular causes may be sub- divided into ischemic and nonischemic etiologies. Myocardial ischemia results from an imbalance between myocardial oxygen supply and demand, such that demand exceeds supply. Ishemic chest pain or angina is most often secondary to obstructive atherosclerotic coronary artery disease (CAD). However, angina is also a feature of valvular heart disease (eg, aortic stenosis), severe hypertension, hypertrophic
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cardiomyopathy, severe pulmonary hypertension (with right ventricular ischemia), and coronary spasm. Angina may also be precipitated by extracardiac conditions, such as severe anemia, hypoxia,
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Chest Pain for Small Group August 25 - Chest Pain Sumanth...

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