Chest Pain Chest pain is a common symptom and may be a manifestation of cardiovascular or noncardiovascular disease. Full characterization of the pain with regard to quality (squeezing, tightening, pressing, burning), quantity, frequency, location, duration, radiation, aggravating or alleviating factors and associated symptoms can help to distinguish the cause. All patients presenting to a hospital with severe or persistent chest pain should have a full set of vital signs, an ECG, and a CXR. **The life-threatening causes that must be considered and ruled out in all patients with severe, persistent chest pain. Cardiac Causes Angina/Myocardial infarction ** Substernal pressure +/- radiation to neck, jaw, Left arm Duration usually > 1 minute and < 12 hours for angina Associated with dyspnea, diaphoresis, nausea/vomiting Worsened with exertion, relieved with rest or nitroglycerin Infarction is same as angina except increased intensity and duration ECG: look for ST elevations or depressions, T wave inversions Pericarditis/Myocarditis ** Sharp pain radiation to trapezius Aggravated by respiration, relieved by sitting forward Listen for pericardial friction rub ECG: look for diffuse ST elevations and PR depressions Aortic Dissection ** Sudden onset of tearing chest pain, knife-life pain Radiation to back Usually severely hypertensive (can become hypotensive) Asymmetric blood pressure in arms and asymmetric pulses bilaterally Widened mediastinum on CXR, new aortic insufficiency murmur Pulmonary Causes Pneumonia ** A very common cause of chest pain in our settings Pleuritic in nature Associated with dyspnea, cough, fever, sputum production Presents with fever, tachycardia, crackles on physical exam CXR should show an infiltrate Pneumothorax ** Sharp, pleuritic pain +/- shortness of breath Unilateral hyperresonance and decrease
Congestive Cardiac Failure (CCF) A complex syndrome caused by a structural or functional abnormality in the cardiac muscle that impairs its ability to function as a pump and meet the metabolic needs of the body. Characterized by shortness of breath, fatigue and signs of fluid retention. Decreased cardiac output triggers the baroreceptors in the the LV, carotid sinus and the aortic arch . This leads to stimulation of the cardio-respiratory centre in the brains, increased ADH release (causing peripheral vasoconstriction and increases renal salt and water absorption) and increased sympathetic stimulation (activating renin – angiotension system, promoting more water retention and peripheral vasoconstriction). These lead to LV dilatation and hypertrophy (poor ejection fraction), increased peripheral vascular resistance (high afterload) and retention of fluid( high preload). Most patients present with left heart failure which can progresses to right heart failure. The most common cause of right heart failure is left heart failure but it can also be caused by pulmonary hypertension (cor pulmonale) or disease that effect the RV>LF (like EMF). Heart failure can be either compensated (when the patient is stable) or decompensated (when the patient suddenly gets worse) Etiology of CHF Systolic Dysfunction (inability to expel blood) Hypertension* Ischemic heart disease Idiopathic cardiomyopathy (like HIV)* Valvular disease* Alcoholic cardiomyopathy Drug-associated cardiomyopathy Myocarditis * The most common causes in our setting Diastolic Dysfunction (abnormal filling) Hypertension Fibrosis Ischemia Aging process Constrictive pericarditis (like TB)* Restrictive pericarditis (like EMF)* Hypertrophic cardiomyopathy
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