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Differential Diagnosis

• Pericarditis
• Acute Myocardial Infarction
• Stable Angina Pectoris
What Is Pericarditis?
• Is a condition in which the membrane, or sac, around your
heart is inflamed. This sac is called the pericardium.
• The pericardium holds the heart in place and helps it work
properly. The sac is made of two thin layers of tissue that
enclose your heart. Between the two layers is a small amount
of fluid. This fluid keeps the layers from rubbing against each
other and causing friction.
Figure A shows the pericardium—the sac surrounding the heart. Figure B is an
enlarged cross-section of the pericardium that shows its two layers of tissue and the
fluid between the layers.
What Causes Pericarditis?
• the cause of about half of all pericarditis cases
(both acute and chronic) is unknown.
• Viral infections are likely the most common
cause of acute pericarditis, but the virus may
never be found. Pericarditis often occurs after a
respiratory infection. Bacterial, fungal, and other
infections also can cause pericarditis.
• Less often, pericarditis is caused by:
 Autoimmune disorders, such as lupus, scleroderma, and rheumatoid
 Heart attack and heart surgery
 Kidney failure, HIV/AIDS, cancer, tuberculosis, and other health problems
 Injury from accidents or radiation therapy
Certain medicines, like phenytoin (an antiseizure medicine), warfarin and
heparin (blood-thinning medicines), and procainamide (a medicine to treat
abnormal heartbeats)
 The causes of acute and chronic pericarditis are the same.
Who Is At Risk for Pericarditis?
• Pericarditis occurs in people of all ages.
However, men between the ages of 20 and 50 are
more likely to get it.
• People who are treated for acute pericarditis
may get it again. This may happen in 15 to 30
percent of people who have the condition. A small
number of these people go on to develop chronic
What Are the Signs and Symptoms of
• Sharp, stabbing chest pain is a common symptom of
acute pericarditis. The pain usually comes on quickly. It
often is felt in the middle or the left side of the chest.
• The pain tends to ease when you sit up and lean
forward. Lying down and deep breathing worsens it.
For some people, the pain feels like a dull ache or
pressure in their chests.
• Fever is another common symptom of acute
pericarditis. Other symptoms are weakness, trouble
breathing, and coughing.
• Chronic pericarditis often causes tiredness,
coughing, and shortness of breath. Chest
pain is often absent in this type of
pericarditis. Severe cases of chronic
pericarditis can lead to swelling in the
stomach and legs and low blood pressure
What symptoms are associated with
• The most common symptom caused by pericarditis is
chest pain. The pain can severe, and is often made worse
by changing position or with deep breathing. Patients can
also have shortness of breath, or fever.
• Pericarditis can produce complications, namely
tamponade, chronic pericarditis, and constriction. These
complications - which are discussed below – can produce
reduced cardiac pumping, lung congestion, and organ
Complications of Pericarditis

• Two serious complications of

pericarditis are:

 cardiac tamponade

chronic constrictive pericarditis.

Cardiac tamponade
• occurs when too much fluid collects in the
pericardium (the sac around the heart). The
extra fluid puts pressure on the heart. This
prevents the heart from properly filling with
blood. As a result, less blood leaves the heart.
This causes a sharp drop in blood pressure. If
left untreated, cardiac tamponade can cause
Chronic constrictive pericarditis
• is a rare disease that develops over time. It
leads to scar-like tissue throughout the
pericardium. The sac becomes stiff and
can’t move properly. In time, the scarred
tissue compresses the heart and prevents it
from working correctly.
Myocardial Infarction (MI)
What is MI?
• "Myocardial Infarction" (abbreviated as "MI")
means there is death of some of the muscle
cells of the heart as a result of a lack of supply
of oxygen and other nutrients.
• is the rapid development of myocardial necrosis
caused by a critical imbalance between oxygen
supply and demand of the myocardium
Cause of MI:
• The most frequent cause of
myocardial infarction (MI) is rupture
of an atherosclerotic plaque within a
coronary artery with subsequent
arterial spasm and thrombus
Other causes:
• Coronary artery vasospasm
• Ventricular hypertrophy (eg, left ventricular hypertrophy
[LVH], idiopathic hypertrophic subaortic stenosis [IHSS],
underlying valve disease)
• Hypoxia due to carbon monoxide poisoning or acute
pulmonary disorders (Infarcts due to pulmonary disease
usually occur when demand on the myocardium
dramatically increases relative to the available blood
• Coronary artery emboli, secondary to cholesterol, air, or
the products of sepsis
• Cocaine, amphetamines, and ephedrine
Other causes:
• Arteritis
• Coronary anomalies, including aneurysms of the
coronary arteries
• Increased afterload or inotropic effects, which
increase the demand on the myocardium
• Aortic dissection, with retrograde involvement
of the coronary arteries
Risk factors:
• Age-older than 45 years old
• Male gender
• Smoking
• Hypercholesterolemia and hypertriglyceridemia,
including inherited lipoprotein disorders
• Diabetes mellitus
• Poorly controlled hypertension
• Family history
• Sedentary lifestyle
Signs & Symptoms:
• Chest pain
• Dyspnea
• Nausea& abdominal pain
• Anxiety
• Lightheadedness with or without syncope
• Cough
• Nausea with or without vomiting
• Diaphoresis
• Wheezing
Complication type: Manifestations:
•Ischemic •Angina, reinfarction, infarct extension
•Heart failure, cardiogenic shock,
mitral valve dysfunction, aneurysms,
•Mechanical cardiac rupture
•Atrial or ventricular arrhythmias, sinus
•Arrhythmic or atrioventricular node dysfunction
•Central nervous system or peripheral
•Embolic embolization

Angina Pectoris
Angina pectoris
• most common clinical manifestation of CAD

• results from an imbalance between myocardial

O2 supply and demand, most commonly
resulting from atherosclerotic coronary artery

• Other major conditions that upset this balance

and result in angina include
– aortic valve disease,
– hypertrophic cardiomyopathy,
• Usually develops gradually with exertion,
emotional excitement, or after heavy
• •Rest or treatment with nitroglycerin leads
to relief.
• In contrast, pain that is fleeting is rarely
ischemic in origin.
• Pain that last for several hours is unlikely
to represent angina.
• Most myocardial perfusion occurs during
diastole, when there is minimal pressure
opposing coronary artery flow.
• Tachycardia decreases the percentage of
time in which the heart is in diastole. It
decreases myocardial perfusion.
• Similar in quality to angina pectoris.
• More prolonged ang severe.
• Occur with the patient at rest, or
awakened from sleep.
• Sublingual nitroglycerin may lead to
transient or no relief.
• Accompanying Sx: Diaphoresis, dyspnea,
nausea and light-headedness.
• Auscultation: During ischemic episodes
there will be presence of third or fourth
heart sounds.
• This reflects myocardial systolic or
diastolic dysfunction.
• Presence of transient murmur of mitral
regurgitation suggests ischemic papillary
muscular dysfunction.
• CAUSES: The spasm often occurs in
coronary arteries that have not become
hardened due to plaque buildup
(atherosclerosis). However, it also can
occur in arteries with plaque buildup.
• The coronary artery may appear normal
during angiography, but it does not
function normally.
• Coronary artery spasm occurs most
commonly in people who smoke or who
have high cholesterol or high blood
• It may be triggered by:Alcohol
withdrawal,emotional stress ,exposure to
cold,medications, and stimulant drugs
such as amphetamines and cocaine.
• Symptoms: Spasm may be "silent" --
without symptoms -- or it may result in
chest pain or angina.
• If the spasm lasts long enough, it may
even cause a heart attack.
• The main symptom is a type of chest pain
called angina, felt under the chest bone
and is described as:
• Constricting,crushing,pressure,squeezing,
• It is usually severe. The pain may spread
to the neck, jaw, shoulder, or arm.
•The pain often occurs at rest and may
occur at the same time each day,usually
between midnight and 8:00 AM
• Lasts from 5 to 30 minutes
• The person may lose consciousness.
• Chest pain and shortness of breath are
often not present during walking and
Angina Pectoris
• P( provoking) – eating too much
» exercise
» emotion
» cold
• P ( Palliating/ relieving) – Rest and Nitroglycerin ( sublingual)
• Q ( quality) – steady; precordial pressure (“hollow-block”)
• - dull, aching, squeezing
• R ( region) – precordial
• R ( radiation) - radiate to Left axilla, left under surface of
arms and forearms—little
finger then it goes up— left shoulder and
• S (severity) – mild-severe