Chest pain

​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

​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