HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18TH EDITION

CARDINAL MANIFESTATIONS AND PRESENTATIONS OF DISEASES:

CHEST DISCOMFORT
Elija Sunga, MD Manila Med

Diagnoses among chest pain patients w/o MI

DIAGNOSIS PERCENT

Gastroesophageal Disease GERD Esophageal Motility Disorder PUD Gallstones

Ischemic Heart Disease Chest Wall Syndromes

42

31 28

Pericarditis
Pleuritis/Pneumonia Pulmonary Embolism

4
2 2

Lung CA
Aortic Aneurysm Aortic Stenosis

1.5
1 1

Herpes Zoster

Causes of Chest Discomfort

A. MYOCARDIAL ISCHEMIA - occurs when the O2 supply to the heart is insufficient to meet metabolic needs - most common underlying cause of myocardial ischemia: obstruction of coronary arteries by atherosclerosis

Causes of Chest Discomfort

A. MYOCARDIAL ISCHEMIA - Other causes: stress, fever, large meals, anemia, hypoxia, hypotension - Ventricular hypertrophy can predispose the myocardium to ischemia because of impaired penetration of blood flow from epicardial coronary arteries to the endocardium

Causes of Chest Discomfort

A. MYOCARDIAL ISCHEMIA 1. Stable Angina - heaviness, pressure, or squeezing - 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

Causes of Chest Discomfort

A. MYOCARDIAL ISCHEMIA 1. Stable Angina - usually retrosternal - may radiate to the neck, jaw, teeth, arms, or shoulders - reflecting common origin in the posterior horn of the SC of sensory neurons supplying the heart and these areas - epigastric pain

Causes of Chest Discomfort

A. MYOCARDIAL ISCHEMIA 1. Stable Angina - develops gradually with exertion, emotional excitement, or after heavy meals - rest or SL nitroglycerin leads to relief w/in minutes - pain that is fleeting is rarely ischemic in origin, also pain that lasts for several hours is unlikely to represent angina

Causes of Chest Discomfort

A. MYOCARDIAL ISCHEMIA 1. Stable Angina - can be precipitated by any physiologic or psychological stress that induces tachycardia

Condition Duration
Stable Angina More than 2 and less than 10 min

Quality
Pressure, tightness, squeezing, heaviness, burning

Location
Retrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, or arms frequently on left

Features
Precipitated by exertion, exposure to cold, psychologic stress

Causes of Chest Discomfort

A. MYOCARDIAL ISCHEMIA 2. Unstable Angina and MI - more prolonged and severe - may occur at rest, or awaken patient from sleep - SL nitroglycerin may lead to transient or no relief - diaphoresis, dyspnea, nausea, and light-headedness

Causes of Chest Discomfort

A. MYOCARDIAL ISCHEMIA - PE may be completely normal in patients with IHD - 3rd or 4th heart sound reflect myocardial systolic or diastolic dysfunction - a transient murmur of mitral regurgitation suggests ischemic papillary muscle dysfunction

Condition Duration
Unstable Angina 10-20 min

Quality

Location

Features
Similar to angina, but occurs with low levels of exertion or even at rest

Similar to Similar to angina but angina often more severe

Condition Duration
Acute MI Variable; often more than 30 min

Quality

Location

Features
Unrelieved by nitroglycerin May be associated with evidence of heart failure or arrhythmia

Similar to Similar to angina but angina often more severe

Condition Duration
Aortic Stenosis Recurrent episodes as described for angina

Quality
As described for angina

Location

Features

As described Latefor angina peaking systolic murmur radiating to carotid arteries

Causes of Chest Discomfort

A. MYOCARDIAL ISCHEMIA 3. Other Cardiac Causes - "cardiac syndrome X: angina-like chest pain and ST-segment depression during stress despite normal coronary arteriograms - have limited changes in coronary flow in response to coronary vasodilators

Causes of Chest Discomfort

B. PERICARDITIS - pain due to inflammation of the adjacent parietal pleura - most of the pericardium is believed to be insensitive to pain

Causes of Chest Discomfort

B. PERICARDITIS - adjacent parietal pleura receives its sensory supply from several sources, so pain can occur in shoulder, neck, abdomen and back - Retrosternal - aggravated by coughing, deep breaths - worse in supine position - relieved by sitting upright and leaning forward

Condition Duration

Quality

Location
Retrosternal or toward cardiac apex; may radiate to left shoulder

Features
May be relieved by sitting up and leaning forward

Pericarditis Hours to Sharp days; may be episodic

Pericardial friction rub

Causes of Chest Discomfort

C. DISEASES OF THE AORTA 1. Aortic Dissection - due to spread of a subintimal hematoma within the wall of the aorta - may begin with a tear in the intima of the aorta or with rupture of the vasa vasorum within the aortic media - nontraumatic aortic dissections are rare in the absence of HPN

Causes of Chest Discomfort

C. DISEASES OF THE AORTA 1. Aortic Dissection - Cystic medial degeneration is a feature of several inherited connective tissue diseases (Marfan and Ehlers-Danlos syndromes) - half of all aortic dissections in women under 40 years of age occur during pregnancy

Causes of Chest Discomfort

C. DISEASES OF THE AORTA 1. Aortic Dissection - the most common presenting complaint is sudden onset of severe, sharp pain - "ripping" and "tearing - Unlike the pain of IHD, symptoms tend to reach peak severity immediately, often causing the patient to collapse from its intensity

Causes of Chest Discomfort

C. DISEASES OF THE AORTA 1. Aortic Dissection - the location often correlates with the site and extent of the dissection - 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

Causes of Chest Discomfort

C. DISEASES OF THE AORTA 1. Aortic Dissection - may compromise flow into arteries branching off the aorta - loss of a pulse in one or both arms, cerebrovascular accident, or paraplegia can all be catastrophic consequences of aortic dissection

Causes of Chest Discomfort

C. DISEASES OF THE AORTA 1. Aortic Dissection - may lead to acute MI or acute aortic insufficiency - rupture of the hematoma into the pericardial space leads to pericardial tamponade

Condition Duration
Aortic Dissection Abrupt onset of unrelentin g pain

Quality
Tearing or ripping sensation; knifelike

Location
Anterior chest, often radiating to back, between shoulder blades

Features
Associated with HPN and/or underlying connective tissue disorder pericardial rub, pericardial tamponade, or loss of peripheral pulses

Causes of Chest Discomfort

C. DISEASES OF THE AORTA 1. Thoracic Aortic Aneurysm - frequently asymptomatic - can cause chest pain by compressing adjacent structures - pain tend to be steady, deep, and sometimes severe

Causes of Chest Discomfort

D. PULMONARY EMBOLISM - pain due to distention of the pulmonary artery or infarction of a segment of the lung adjacent to the pleura - Massive PE may lead to substernal pain that is suggestive of MI - more commonly, smaller emboli lead to focal pulmonary infarctions that cause pain that is lateral and pleuritic

Causes of Chest Discomfort

D. PULMONARY EMBOLISM - dyspnea, hemoptysis, tachycardia - although not always present, certain characteristic ECG changes can support the diagnosis

Condition Duration

Quality

Location
Often lateral, on the side of the embolism

Features
Dyspnea, tachypnea, tachycardia, and hypotension

Pulmonary Abrupt Pleuritic Embolism onset; several minutes to a few hours

Condition Duration
Pulmonary Variable HPN

Quality
Pressure

Location
Substernal

Features
Dyspnea, signs of increased venous pressure including edema and jugular venous distention

Causes of Chest Discomfort

E. PNEUMOTHORAX - sudden onset of pleuritic chest pain and respiratory distress - may occur without a precipitating event in persons without lung disease, or as a consequence of underlying lung disorders

Condition Duration
Spontaneo us Pneumoth orax Sudden onset; several hours

Quality
Pleuritic

Location
Lateral to side of pneumothor ax

Features
Dyspnea, decreased breath sounds on side of pneumothor ax

Causes of Chest Discomfort

F. PNEUMONIA - damage and cause inflammation of the pleura of the lung - sharp, knifelike pain - aggravated by inspiration or coughing

Condition Duration
Pneumonia Variable

Quality
Pleuritic

Location
Unilateral, often localized

Features
Dyspnea, cough, fever, rales, occasional rub

Causes of Chest Discomfort

G. GI CONDITIONS 1. GERD - deep burning discomfort - exacerbated by alcohol, ASA, or some foods - relieved by antacid or other acidreducing therapies

Causes of Chest Discomfort

G. GI CONDITIONS 1. GERD - exacerbated by lying down - may be worse in early morning

Condition Duration
Reflux

Quality

Location
Substernal, epigastric

Features
Worsened by postprandial recumbency Relieved by antacids

1060 min Burning

Causes of Chest Discomfort

G. GI CONDITIONS 2. Esophageal Spasm - squeezing pain indistinguishable from angina - prompt relief is often provided by antianginal therapies (nifedipine)

Condition Duration
Esophageal spasm 230 min

Quality
Pressure, tightness, burning

Location

Features

Retrosternal Can closely mimic angina

Causes of Chest Discomfort

G. GI CONDITIONS 3. Mallory-Weiss Tear - chest pain result from injury to the esophagus - caused by severe vomiting

Causes of Chest Discomfort

G. GI CONDITIONS 4. PUD, Biliary Disease - usually cause abdominal pain as well as chest discomfort - not likely to be associated with exertion - PUD: pain typically occurs 60 to 90 min after meals - Cholecystitis: aching pain, occurring an hour or more after meals

Condition Duration
PUD Prolonged

Quality
Burning

Location
Epigastric, substernal

Features
Relieved with food or antacids

Condition Duration
Gallbladder Disease Prolonged

Quality
Burning, pressure

Location
Epigastric, right upper quadrant, substernal

Features
May follow meal

Condition Duration
Musculoskeletal Disease Variable

Quality
Aching

Location
Variable

Features
Aggravated by movement May be reproduced by localized pressure on examination

Causes of Chest Discomfort

H. NEUROMUSCULAR CONDITIONS 1. Costochondral Syndrome - most common cause of anterior chest musculoskeletal pain - occasionally swelling, redness, and warmth (Tietze's syndrome) occur - usually fleeting and sharp pain, but can present as dull ache lasting for hours - direct pressure on the costochondral junctions may reproduce

Causes of Chest Discomfort

H. NEUROMUSCULAR CONDITIONS 2. Cervical Disk Disease - cause chest pain by compression of nerve roots 3. Herpes Zoster - pain in a dermatomal distribution

Condition Duration
Herpes Zoster Variable

Quality
Sharp or burning

Location

Features

Dermatomal Vesicular distribution rash in area of discomfort

Causes of Chest Discomfort

I. EMOTIONAL AND PSYCHIATRIC CONDITIONS - 10% of patients presenting at the ER with acute chest discomfort have panic disorder or other emotional conditions - symptoms are highly variable - tightness or aching that lasts more than 30 min

Causes of Chest Discomfort

I. EMOTIONAL AND PSYCHIATRIC CONDITIONS - ECG may be difficult to interpret if hyperventilation causes ST-T-wave abnormalities - careful history may elicit clues of depression, prior panic attacks, somatization, agoraphobia, or other phobias

Condition Duration
Emotional Variable; and may be psychiatric fleeting conditions

Quality
Variable

Location
Variable; may be retrosternal

Features
Situational factors may precipitate symptoms Anxiety or depression often detectable with careful history

Approach to the Patient with Chest Discomfort

focus first on identifying patients who require aggressive interventions to manage potentially life-threatening conditions address safety of discharge to home, admission to a non-ICU facility

Approach to the Patient with Chest Discomfort

1. Could the chest discomfort be due to an acute, potentially life-threatening condition that warrants immediate hospitalization and aggressive evaluation? *Aortic Dissection *Pulmonary Embolism *Acute Ischemic Heart Disease *Spontaneous pneumothorax

Approach to the Patient with Chest Discomfort

2. If not, could the discomfort be due to a chronic condition likely to lead to serious complications? *Stable Angina *Aortic Stenosis *Pulmonary HPN

Approach to the Patient with Chest Discomfort

3. If not, could the discomfort be due to an acute condition that warrants specific treatment? *Pericarditis *Pneumonia/Pleuritis *Herpes Zoster

Approach to the Patient with Chest Discomfort

4. If not, could the discomfort be due to another treatable chronic condition? *GERD *PUD *Esophageal spasm *Anxiety state *GB disease *Costochondritis *Other muscular disorder *Arthritis of shoulder or spine

Approach to the Patient with Chest Discomfort

Myocardial ischemia is usually associated with a gradual intensification of symptoms over a period of minutes Pain that is fleeting or that lasts hours without ECG changes is not likely to be ischemic in origin

Approach to the Patient with Chest Discomfort

wide radiation of chest pain increases probability that pain is due to MI radiation to the L arm is common with acute IHD, but radiation to the R arm is also highly consistent with this diagnosis

Approach to the Patient with Chest Discomfort

R shoulder pain is common with acute cholecystitis, but this is usually accompanied by abdominal pain rather than chest pain chest pain radiating between the scapulae raises the question of aortic dissection

Physical Exam
BP of both arms pulses in both legs pericardial rubs systolic and diastolic murmurs third or fourth heart sounds pressure on the chest wall may reproduce symptoms in patients with musculoskeletal cause

Diagnostics
presence of ECG changes consistent with ischemia or infarction is associated with high risks of acute MI risk of life-threatening complications is low for patients with normal or only NSSTWC if these patients are not considered appropriate for immediate discharge, they are often candidates for early exercise testing

Prevalence of Acute IHD among ER Px w/ CP

Finding ST elevation (>=1 mm) or Q waves on ECG not known to be old Ischemia or strain on ECG not known to be old (ST depression >= 1 mm or ischemic T waves) None of the preceding ECG changes but a prior history of angina or MI (history of heart attack or nitroglycerin use) None of the preceding ECG changes and no prior history of angina or MI (history of heart attack or nitroglycerin use) Prevalence of MI 79% 20% UA 12% 41%

4%

51%

2%

14%

Diagnostics
Cardiac Markers - Troponins I and T have superceded creatine kinase and CK-MB as the markers of choice for detecting myocardial injury - Single values of these markers do not have high sensitivity for acute MI or for prediction of complications

Diagnostics
Clinicians frequently employ therapeutic trials with SL nitroglycerin, antacids or PPI A common error is to assume that a response to any of these interventions clarifies the diagnosis patient's response may be due to the placebo effect

Guidelines advocate:
ECG for all patients with chest pain who do not have an obvious noncardiac cause of their pain CXR for patients with signs or symptoms consistent with CHF, VHD, pericardial disease, aortic dissection or aneurysm

Guidelines emphasize:
Rapid identification and treatment of patients for whom emergent reperfusion therapy, either via PCI or thrombolytic agents, is likely to lead to improved outcomes

Guidelines emphasize:
patients with low risk for complications can be observed in non-coronary care unit settings, undergo early exercise testing, or be discharged home minimum length of stay in a monitored bed for a patient who has no further symptoms: 12h or less if exercise testing is available

HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18TH EDITION

CARDINAL MANIFESTATIONS AND PRESENTATIONS OF DISEASES:

PALPITATIONS

Palpitations:
"thumping," "pounding," or "fluttering" sensation in the chest can be either intermittent or sustained and either regular or irregular unusual awareness of the heartbeat often noted when the patient is quietly resting, during which time other stimuli are minimal

Palpitations:
palpitations that are positional generally reflect a structural process within (atrial myxoma) or adjacent to (mediastinal mass) the heart

Palpitations:
cardiac (43%) psychiatric (31%) miscellaneous (10%) unknown cause (16%)

Palpitations: Cardiac
intermittent: PAC, PVC regular, sustained: SVT, VTach irregular, sustained: AF most arrhythmias are not associated with palpitations ask the patient to "tap out" the rhythm of the palpitations or to take his pulse while experiencing palpitations

Palpitations: Cardiac
hyperdynamic states caused by catecholamine stimulation from exercise, stress, or pheochromocytoma can lead to palpitations common among athletes, especially older endurance athletes

Palpitations: Cardiac
AR: enlarged ventricle and accompanying hyperdynamic precordium lead to palpitations factors that enhance the strength of myocardial contraction: tobacco, caffeine, aminophylline, atropine, thyroxine, cocaine, amphetamines

Palpitations: Psychiatric
panic attacks anxiety states somatization Patients with psychiatric causes for palpitations more commonly report a longer duration (>15 min) and other accompanying symptoms than do patients with other causes

Palpitations: Miscellaneous
thyrotoxicosis drugs ethanol spontaneous skeletal muscle contractions of the chest wall pheochromocytoma systemic mastocytosis

Approach to Palpitations
principal goal: determine if caused by a life-threatening arrhythmia patients with preexisting CAD or risk factors for CAD are at greatest risk for ventricular arrhythmias as a cause for palpitations

Approach to Palpitations
ECG: to document arrhythmia If exertion is known to induce arrhythmia and palpitations, exercise ECG can be used If arrhythmia is infrequent: Holter monitoring, telephonic monitoring, implantable loop recorder

Approach to Palpitations
Most patients with palpitations do not have serious arrhythmias or underlying structural heart disease Occasional benign PAC or PVC can often be managed with beta-blocker if sufficiently troubling to the patient Abstinence from alcohol, tobacco, or illicit drugs

Approach to Palpitations
psychiatric causes may benefit from cognitive or pharmacotherapies palpitations are at the very least bothersome and could be frightening to the patient Once serious causes for the symptom have been excluded, the patient should be reassured that the palpitations will not adversely affect prognosis

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