Cardiac- Common PC- Acute Chest Pain And Dyspnoea

Question 1

Acute pain- MI type pain.

Answer 1

• Myocardial infarction causes symptoms that are similar to, but more severe and prolonged than, those of angina pectoris.
• Character- constricting/heavy
• Associated features include restlessness, breathlessness and a feeling of impending death (angor animi).
• Radiation to one or-both arms/shoulders,
• an association with exertion, sweating, nausea or vomiting and similarity to previous myocardial infarc-tion all increase the likelihood of acute myocardial infarction.
• Pain that is pleuritic, positional, sharp, or reproduced with palpation is unlikely to be due to myocardial infarction.

Question 2

Pericardial pain

Answer 2

• Pericardial pain is typically a constant anterior central chest pain that may radiate to the shoulders.
• It tends to be sharp or stabbing in character
• exacerbated by inspiration or lying down, and relieved by sitting forwards.
• It is caused by inflammation of the pericardium secondary to viral infection, connective tissue disease or myocardial infarction, or after surgery, catheter abla-tion or radiotherapy.

Question 3

AORTIC ANEURSYM

Answer 3

• Aortic dissection (a tear in the intima of the thoracic aorta) is a life-threatening condition which is often missed.
• It is associated with abrupt onset of very severe,
• character and radiation- tearing chest pain that can radiate to the back (typically the interscapular region)
• may be associatedwith profound autonomic stimulation.
• Over 90% of patients report the pain as severe or their ‘worst ever’, and the
• onset is sudden in 85% of cases; the absence of abrupt onset makes the diagnosis less likely.
• If the tear involves the cranial or upper limb arteries, there may be associated syncope, stroke or upper limb pulse asymme-try.
• Predisposing factors include connective tissue disorders,such as Marfan’s syndrome (see Fig.3.21A-D), family history of aortic disease, known aortic valve disease, previous aortic manipulation and known thoracic aortic aneurysm.
• As with intermittent chest pain, explore the characteristics of the pain, and ask specifically about associated symptoms that guide a diagnosis e.g. neurological Sx, intrascapular pain, sweating

Question 4

Dyspnoea- cardiac causes

Answer 4

• Heart failure is the most common cardiovascular cause of both acute and chronic dyspnoea
• ## Other cardiovascular causes of acute breathlessness include ACS, valvular heart disease, pulmonary embolism and arrhythmia,

Question 5

Dyspnoea- non cardiac causes

Answer 5

• whilst non-cardiac dyspnoea may be due to pulmonary disease, obesity, anaemia, neuromuscular disease, chest wall disorders, pregnancy, hyperventilation syndrome and anxiety disorders.

Question 6

Dyspnoea- correct position HF vs Pe

Answer 6

• Patients with acute heart failure and pulmonary oedema (accumulation of fluid in the alveoli) usually prefer to be upright,
• while patients with massive pulmonary embolism are often more comfortable lying flat and may faint (syncope) if made to sit upright.

Question 7

Exceptional dyspnoea in HF

Answer 7

• Exertional dyspnoea is the symptomatic hallmark of chronic heart failure.
• The New York Heart Association grading system isused to assess the degree of symptomatic limitationj caused by the exertional breathlessness of heart failure (Box 4.6).

Question 8

Orthopnoea- what is it, mechanism in HF, Sx in HF

Answer 8

• Orthopnoea, dyspnoea on lying flat, may occur in patients with heart failure,
• where it signifies advanced disease or incipient decompensation.
• Lying flat increases venous return and in patients with left ventricular impairment may precipitate pulmonary oedema.
• The severity can be graded by the number of pillows used at night: ‘three-pillow orthopnoea’, for example.
  Paroxysmal nocturnal dyspnoea is caused by the same mechanism, resulting in sudden breathlessness that wakes the patient from sleep (Fig. 4.3).
• Patients may choke or gasp for air, sit on the edge of the bed and open windows in an attempt to relieve their distress.
• It may be confused with asthma, which can also cause night-time dyspnoea, chest tightness, cough and wheeze, but patients with heart failure may also produce frothy white or blood-stained sputum.

Question 9

Acute Dyspneoa- what to ask about

Answer 9

• duration of onset
• background symptoms of exertional dyspnoea and usual exercise tolerance
• associated symptoms: chest pain, syncope, palpitation or respiratory symptoms (such as cough, sputum, wheeze or haemoptysis).

Question 10

Chronic dyspnoea- what to ask about

Answer 10

• relationship between symptoms and exertion
• degree of limitation caused by symptoms and their impact on everyday activities
• effect of posture on symptoms and/or episodes of nocturnal breathlessness
• associated symptoms: ankle swelling, cough, wheeze and sputum