HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18TH EDITIONCARDINAL MANIFESTATIONS AND PRESENTATIONS OF DISEASES: CHEST DISCOMFORT

Elija Sunga, MDManila Med

Diagnoses among chest pain patients w/o MI

DIAGNOSISPERCENTGastroesophageal Disease GERD Esophageal Motility Disorder PUD Gallstones42Ischemic Heart Disease31Chest Wall Syndromes28Pericarditis4Pleuritis/Pneumonia2Pulmonary Embolism2Lung CA1.5Aortic Aneurysm1Aortic Stenosis1Herpes Zoster1

Causes of Chest DiscomfortA. MYOCARDIAL ISCHEMIAoccurs 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 DiscomfortA. MYOCARDIAL ISCHEMIAOther 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 DiscomfortA. MYOCARDIAL ISCHEMIA1. Stable Anginaheaviness, pressure, or squeezingsome patients deny any "pain" but may admit to dyspnea or a vague sense of anxietyThe word "sharp" is sometimes used by patients to describe intensity rather than quality

Causes of Chest DiscomfortA. MYOCARDIAL ISCHEMIA1. Stable Anginausually retrosternalmay radiate to the neck, jaw, teeth, arms, or shouldersreflecting common origin in the posterior horn of the SC of sensory neurons supplying the heart and these areasepigastric pain

Causes of Chest DiscomfortA. MYOCARDIAL ISCHEMIA1. Stable Anginadevelops gradually with exertion, emotional excitement, or after heavy mealsrest or SL nitroglycerin leads to relief w/in minutespain that is fleeting is rarely ischemic in origin, also pain that lasts for several hours is unlikely to represent angina

Causes of Chest DiscomfortA. MYOCARDIAL ISCHEMIA1. Stable Anginacan be precipitated by any physiologic or psychological stress that induces tachycardia

ConditionDurationQualityLocationFeaturesStable AnginaMore than 2 and less than 10 minPressure, tightness, squeezing, heaviness, burningRetrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, or armsfrequently on leftPrecipitated by exertion, exposure to cold, psychologic stress

Causes of Chest DiscomfortA. MYOCARDIAL ISCHEMIA2. Unstable Angina and MImore prolonged and severemay occur at rest, or awaken patient from sleepSL nitroglycerin may lead to transient or no reliefdiaphoresis, dyspnea, nausea, and light-headedness

Causes of Chest DiscomfortA. MYOCARDIAL ISCHEMIAPE may be completely normal in patients with IHD3rd or 4th heart sound reflect myocardial systolic or diastolic dysfunction a transient murmur of mitral regurgitation suggests ischemic papillary muscle dysfunction

ConditionDurationQualityLocationFeaturesUnstable Angina10-20 minSimilar to angina but often more severeSimilar to anginaSimilar to angina, but occurs with low levels of exertion or even at rest

ConditionDurationQualityLocationFeaturesAcute MIVariable; often more than 30 minSimilar to angina but often more severeSimilar to anginaUnrelieved by nitroglycerin

May be associated with evidence of heart failure or arrhythmia

ConditionDurationQualityLocationFeaturesAortic StenosisRecurrent episodes as described for anginaAs described for anginaAs described for anginaLate-peaking systolic murmur radiating to carotid arteries

Causes of Chest DiscomfortMYOCARDIAL ISCHEMIA3. Other Cardiac Causes"cardiac syndrome X: angina-like chest pain and ST-segment depression during stress despite normal coronary arteriogramshave limited changes in coronary flow in response to coronary vasodilators

Causes of Chest DiscomfortB. PERICARDITISpain due to inflammation of the adjacent parietal pleuramost of the pericardium is believed to be insensitive to pain

Causes of Chest DiscomfortB. PERICARDITISadjacent parietal pleura receives its sensory supply from several sources, so pain can occur in shoulder, neck, abdomen and backRetrosternalaggravated by coughing, deep breathsworse in supine positionrelieved by sitting upright and leaning forward

ConditionDurationQualityLocationFeaturesPericarditisHours to days; may be episodicSharpRetrosternal or toward cardiac apex; may radiate to left shoulderMay be relieved by sitting up and leaning forward

Pericardial friction rub

Causes of Chest DiscomfortC. DISEASES OF THE AORTAAortic Dissectiondue to spread of a subintimal hematoma within the wall of the aortamay begin with a tear in the intima of the aorta or with rupture of the vasa vasorum within the aortic medianontraumatic aortic dissections are rare in the absence of HPN

Causes of Chest DiscomfortC. DISEASES OF THE AORTAAortic DissectionCystic 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 DiscomfortC. DISEASES OF THE AORTAAortic Dissectionthe most common presenting complaint is sudden onset of severe, sharp pain"ripping" and "tearingUnlike the pain of IHD, symptoms tend to reach peak severity immediately, often causing the patient to collapse from its intensity

Causes of Chest DiscomfortC. DISEASES OF THE AORTAAortic Dissectionthe location often correlates with the site and extent of the dissectiondissections 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 DiscomfortC. DISEASES OF THE AORTAAortic Dissectionmay compromise flow into arteries branching off the aortaloss of a pulse in one or both arms, cerebrovascular accident, or paraplegia can all be catastrophic consequences of aortic dissection

Causes of Chest DiscomfortC. DISEASES OF THE AORTAAortic Dissectionmay lead to acute MI or acute aortic insufficiencyrupture of the hematoma into the pericardial space leads to pericardial tamponade

ConditionDurationQualityLocationFeaturesAortic DissectionAbrupt onset of unrelenting painTearing or ripping sensation; knifelikeAnterior chest, often radiating to back, between shoulder bladesAssociated with HPN and/or underlying connective tissue disorder

pericardial rub, pericardial tamponade, or loss of peripheral pulses

Causes of Chest DiscomfortC. DISEASES OF THE AORTAThoracic Aortic Aneurysmfrequently asymptomaticcan cause chest pain by compressing adjacent structurespain tend to be steady, deep, and sometimes severe

Causes of Chest DiscomfortD. PULMONARY EMBOLISMpain due to distention of the pulmonary artery or infarction of a segment of the lung adjacent to the pleuraMassive PE may lead to substernal pain that is suggestive of MImore commonly, smaller emboli lead to focal pulmonary infarctions that cause pain that is lateral and pleuritic

Causes of Chest DiscomfortD. PULMONARY EMBOLISMdyspnea, hemoptysis, tachycardia although not always present, certain characteristic ECG changes can support the diagnosis

ConditionDurationQualityLocationFeaturesPulmonary EmbolismAbrupt onset; several minutes to a few hoursPleuriticOften lateral, on the side of the embolismDyspnea, tachypnea, tachycardia, and hypotension

ConditionDurationQualityLocationFeaturesPulmonary HPNVariablePressureSubsternalDyspnea, signs of increased venous pressure including edema and jugular venous distention

Causes of Chest DiscomfortE. PNEUMOTHORAXsudden 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

ConditionDurationQualityLocationFeaturesSpontaneous PneumothoraxSudden onset; several hoursPleuriticLateral to side of pneumothoraxDyspnea, decreased breath sounds on side of pneumothorax

Causes of Chest DiscomfortF. PNEUMONIAdamage and cause inflammation of the pleura of the lungsharp, knifelike pain aggravated by inspiration or coughing

ConditionDurationQualityLocationFeaturesPneumoniaVariablePleuriticUnilateral, often localizedDyspnea, cough, fever, rales, occasional rub

Causes of Chest DiscomfortG. GI CONDITIONS1. GERDdeep burning discomfortexacerbated by alcohol, ASA, or some foodsrelieved by antacid or other acid-reducing therapies

Causes of Chest DiscomfortG. GI CONDITIONS1. GERDexacerbated by lying downmay be worse in early morning

ConditionDurationQualityLocationFeaturesReflux1060 minBurningSubsternal, epigastricWorsened by postprandial recumbency

Relieved by antacids

Causes of Chest DiscomfortG. GI CONDITIONS2. Esophageal Spasmsqueezing pain indistinguishable from anginaprompt relief is often provided by antianginal therapies (nifedipine)

ConditionDurationQualityLocationFeaturesEsopha-geal spasm230 minPressure, tightness, burningRetrosternalCan closely mimic angina

Causes of Chest DiscomfortG. GI CONDITIONS3. Mallory-Weiss Tearchest pain result from injury to the esophaguscaused by severe vomiting

Causes of Chest DiscomfortG. GI CONDITIONS4. PUD, Biliary Diseaseusually cause abdominal pain as well as chest discomfortnot likely to be associated with exertionPUD: pain typically occurs 60 to 90 min after mealsCholecystitis: aching pain, occurring an hour or more after meals

ConditionDurationQualityLocationFeaturesPUDProlongedBurningEpigastric, substernalRelieved with food or antacids

ConditionDurationQualityLocationFeaturesGall-bladder DiseaseProlongedBurning, pressureEpigastric, right upper quadrant, substernalMay follow meal

ConditionDurationQualityLocationFeaturesMusculo-skeletal DiseaseVariableAchingVariableAggravated by movementMay be reproduced by localized pressure on examination

Causes of Chest DiscomfortH. NEUROMUSCULAR CONDITIONS1. Costochondral Syndromemost common cause of anterior chest musculoskeletal painoccasionally swelling, redness, and warmth (Tietze's syndrome) occurusually fleeting and sharp pain, but can present as dull ache lasting for hoursdirect pressure on the costochondral junctions may reproduce

Causes of Chest DiscomfortH. NEUROMUSCULAR CONDITIONS2. Cervical Disk Diseasecause chest pain by compression of nerve roots3. Herpes Zosterpain in a dermatomal distribution

ConditionDurationQualityLocationFeaturesHerpes ZosterVariableSharp or burningDermatomal distributionVesicular rash in area of discomfort

Causes of Chest DiscomfortI. EMOTIONAL AND PSYCHIATRIC CONDITIONS10% of patients presenting at the ER with acute chest discomfort have panic disorder or other emotional conditionssymptoms are highly variabletightness or aching that lasts more than 30 min

Causes of Chest DiscomfortI. EMOTIONAL AND PSYCHIATRIC CONDITIONSECG may be difficult to interpret if hyperventilation causes ST-T-wave abnormalitiescareful history may elicit clues of depression, prior panic attacks, somatization, agoraphobia, or other phobias

ConditionDurationQualityLocationFeaturesEmotional and psychiatricconditionsVariable; may be fleetingVariableVariable; may be retrosternalSituational factors may precipitate symptoms

Anxiety or depression often detectable with careful history

Approach to the Patient with Chest Discomfortfocus first on identifying patients who require aggressive interventions to manage potentially life-threatening conditionsaddress safety of discharge to home, admission to a non-ICU facility

Approach to the Patient with Chest Discomfort1. 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 Discomfort2. 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 Discomfort3. 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 Discomfort4. 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 DiscomfortMyocardial ischemia is usually associated with a gradual intensification of symptoms over a period of minutesPain that is fleeting or that lasts hours without ECG changes is not likely to be ischemic in origin

Approach to the Patient with Chest Discomfortwide radiation of chest pain increases probability that pain is due to MIradiation 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 DiscomfortR shoulder pain is common with acute cholecystitis, but this is usually accompanied by abdominal pain rather than chest painchest pain radiating between the scapulae raises the question of aortic dissection

Physical ExamBP of both armspulses in both legspericardial rubssystolic and diastolic murmursthird or fourth heart soundspressure on the chest wall may reproduce symptoms in patients with musculoskeletal cause

Diagnosticspresence of ECG changes consistent with ischemia or infarction is associated with high risks of acute MIrisk of life-threatening complications is low for patients with normal or only NSSTWCif 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

FindingPrevalence of MIUAST elevation (>=1 mm) or Q waves on ECG not known to be old79%12%Ischemia or strain on ECG not known to be old (ST depression >= 1 mm or ischemic T waves)20%41%None of the preceding ECG changes but a prior history of angina or MI (history of heart attack or nitroglycerin use)4%51%None of the preceding ECG changes and no prior history of angina or MI (history of heart attack or nitroglycerin use)2%14%

DiagnosticsCardiac MarkersTroponins I and T have superceded creatine kinase and CK-MB as the markers of choice for detecting myocardial injurySingle values of these markers do not have high sensitivity for acute MI or for prediction of complications

DiagnosticsClinicians frequently employ therapeutic trials with SL nitroglycerin, antacids or PPIA common error is to assume that a response to any of these interventions clarifies the diagnosispatient'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 painCXR 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 homeminimum 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 EDITIONCARDINAL MANIFESTATIONS AND PRESENTATIONS OF DISEASES: PALPITATIONS

Palpitations:"thumping," "pounding," or "fluttering" sensation in the chestcan be either intermittent or sustained and either regular or irregularunusual 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: Cardiacintermittent: PAC, PVC regular, sustained: SVT, VTachirregular, sustained: AFmost arrhythmias are not associated with palpitationsask the patient to "tap out" the rhythm of the palpitations or to take his pulse while experiencing palpitations

Palpitations: Cardiachyperdynamic states caused by catecholamine stimulation from exercise, stress, or pheochromocytoma can lead to palpitationscommon among athletes, especially older endurance athletes

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

Palpitations: Psychiatricpanic attacksanxiety statessomatizationPatients with psychiatric causes for palpitations more commonly report a longer duration (>15 min) and other accompanying symptoms than do patients with other causes

Palpitations: Miscellaneousthyrotoxicosisdrugs ethanolspontaneous skeletal muscle contractions of the chest wallpheochromocytomasystemic mastocytosis

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

Approach to PalpitationsECG: to document arrhythmiaIf exertion is known to induce arrhythmia and palpitations, exercise ECG can be usedIf arrhythmia is infrequent: Holter monitoring, telephonic monitoring, implantable loop recorder

Approach to PalpitationsMost patients with palpitations do not have serious arrhythmias or underlying structural heart diseaseOccasional benign PAC or PVC can often be managed with beta-blocker if sufficiently troubling to the patientAbstinence from alcohol, tobacco, or illicit drugs

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

THANK YOU

Chest discomfort is a common challenge for clinicians. The differential diagnosis includes conditions affecting organs throughout the thorax and abdomen, with prognosis varying from benign to life-threatening. Failure to recognize potentially serious conditions such as acute ischemic heart disease, aortic dissection, tension pneumothorax, or PE can lead to serious complications, including death.

**result from a decrease in O2 supply or a rise in demand

**The chest discomfort of myocardial ischemia is a visceral discomfort that is usually described as a heaviness, pressure, or squeezing. *most patients do not localize the pain to any small area*most patients do not localize the pain to any small area*Most myocardial perfusion occurs during diastole, when there is minimal pressure opposing coronary artery flow from within the left ventricle. Since tachycardia decreases the percentage of the time in which the heart is in diastole, it decreases myocardial perfusion.

**

*******all of which lead to movements of pleural surfaces. **can occur with trauma to the aorta

******Murmur of aortic insufficiency, ***S1Q3T3 pattern - a prominent S wave in lead I a Q wave and inverted T wave in lead III

*Murmur of aortic insufficiency, *Murmur of aortic insufficiency, *should lead to consideration of spontaneous pneumothorax, as well as PE

*Murmur of aortic insufficiency, **Murmur of aortic insufficiency, **when the stomach is empty of food that might otherwise absorb gastric acid

*Murmur of aortic insufficiency, *further promoting confusion between these syndromes(usually occurs in a patient with a history of heartburn, reflux, dysphagia, or symptomatic hiatal hernia. The pain of esophageal spasm is poorly localized, and may mimic angina in nature and severity. The pain usually follows a meal, or may be provoked by the act of swallowing)*Murmur of aortic insufficiency, **when postprandial acid production is no longer neutralized by food in the stomach *Murmur of aortic insufficiency, *Murmur of aortic insufficiency, *Murmur of aortic insufficiency, **Chest pain symptoms due to herpes zoster may occur before skin lesions are apparent.

*Murmur of aortic insufficiency, *Some patients offer other atypical descriptions, such as pain that is fleeting, sharp, and/or localized to a small region. **Murmur of aortic insufficiency, *including acute ischemic heart disease, acute aortic dissection, pulmonary embolism, and tension pneumothorax*Presented a sequence of questions that can be used in the evaluation of the patient with chest discomfort, with the diagnostic entities that are most important for consideration at each stage of the evaluation*displays a sequence of questions that can be used in the evaluation of the patient with chest discomfort, with the diagnostic entities that are most important for consideration at each stage of the evaluation*displays a sequence of questions that can be used in the evaluation of the patient with chest discomfort, with the diagnostic entities that are most important for consideration at each stage of the evaluation*displays a sequence of questions that can be used in the evaluation of the patient with chest discomfort, with the diagnostic entities that are most important for consideration at each stage of the evaluation*Although the presence of risk factors for coronary artery disease may heighten concern for this diagnosis, the absence of such risk factors does not lower the risk for myocardial ischemia enough to be used to justify a decision to discharge a patient

**shows estimates derived from several studies of the impact of clinical features from the history on the probability that a patient has an acute MI

*poor perfusion of a limb may be due to aortic dissection compromising flow to an artery branching from the aortait is important that the clinician ask the patient if the chest pain syndrome is being completely reproduced before drawing too much reassurance that more serious underlying conditions are not present

*absence of ECG changes does not exclude acute IHD, but the risk of life-threatening complications is low for patients with normal or only NSSTWC

**decisions to discharge patients home should not be made on the basis of single negative values of these tests, including the cardiac troponins

*Hence, myocardial ischemia should never be considered excluded solely because of a response to antacid therapySimilarly, failure of nitroglycerin to relieve pain does not exclude the diagnosis of coronary disease.

*Guidelines developed by the American College of Cardiology, American Heart Association, and other organizations*Many medical centers have adopted critical pathways and other forms of guidelines to increase efficiency and to expedite the treatment of patients with high-risk acute ischemic heart disease syndromes. These guidelines emphasize the following strategies

*such as patients without new ischemic changes on their ECGs and without ongoing chest pain. ****the post-extrasystolic beat is sensed by the patient owing to the increase in ventricular end-diastolic dimension following the pause in the cardiac cycle and the increased strength of contraction (post-extrasystolic potentiation) of that beat.

****tobacco, caffeine, aminophylline, atropine, thyroxine, cocaine, amphetamines*including syncope or lightheadedness, *telephonic monitoring, through which the patient can transmit an electrocardiographic tracing during a sensed episodeloop recordings (external or implantable), which can capture the electrocardiographic event for later review***