Chapter 013. Chest Discomfort (Part 2) Angina Pectoris (See also Chap. 237) The chest discomfort of myocardial ischemia is a visceral discomfort that is usually described as a heaviness, pressure, or squeezing (Table 13-2). Other common adjectives for anginal pain are burning and aching. 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. Table 13-2 Typical Clinical Features of Major Causes of Acute Chest Discomfort Condition Durati on Qualit y Location Associat ed Features Angina More than 2 and less than 10 min Pressu re, tightness, squeezing, heaviness, burning Retroster nal, often with radiation to or isolated discomfort in neck, jaw, sh oulders, or arms— frequently on left Precipita ted by exertion, exposure to cold, psychologic stress S 4 gallop or mitral regurgitation murmur during pain Unstable angina 10–20 min Simila r to angina but often more severe Similar to angina Similar to angina, but occurs with low levels of exertion or even at rest Acute Variabl Simila Similar to Unreliev myocardial infarction e; often more than 30 min r to angina but often more severe angina ed by nitroglycerin May be associated with evidence of heart failure or arrhythmia Aortic stenosis Recurr ent episodes as described for angina As described for angina As described for angina Late- peaking systolic murmur radiating to carotid arteries Pericarditis Hours to days; may be episodic Sharp Retroster nal or toward card iac apex; may radiate to left shoulder May be relieved by sitting up and leaning forward Pericardi al friction rub Aortic dissection Abrupt onset of unrelenting pain Tearin g or ripping sensation; knifelike Anterior chest, often radiating to back, between shoulder blades Associat ed with hypertension and/or underlying connective tissue disorder, e.g., Marfan syndrome Murmur of aortic insufficiency, pericardial rub, pericardial tamponade, or loss of peripheral pulses Pulmonary Abrupt Pleurit Often Dyspnea embolism onset; several m inutes to a few hours ic lateral, on the side of the embolism , tachypnea, tachycardia, and hypotension Pulmonary hypertension Variabl e Pressu re Substerna l Dyspnea , signs of increased venous pressure including edema and jugular venous distention Pneumonia or pleuritis Variabl e Pleurit ic Unilateral , often localized Dyspnea , cough, fever, rales, occasional rub Spontaneous pneumothorax Sudden onset; several Pleurit ic Lateral to side of Dyspnea , decreased hours pneumothorax breath sounds on side of pneumothorax Esophageal reflux 10–60 min Burni ng Substerna l, epigastric Worsene d by postprandial recumbency Relieved by antacids Esophageal spasm 2–30 min Pressu re, tightness, burning Retroster nal Can closely mimic angina Peptic ulcer Prolon ged Burni ng Epigastri c, substernal Relieved with food or antacids Gallbladder Prolon Burni Epigastri c, right upper May disease ged ng, pressure quadrant, substernal follow meal Musculoskel etal disease Variabl e Achin g Variable Aggravat ed by movement May be reproduced by localized pressure on examination Herpes zoster Variabl e Sharp or burning Dermato mal distribution Vesicula r rash in area of discomfort Emotional and psychiatric conditions Variabl e; may be fleeting Variab le Variable; may be retrosternal Situation al factors may precipitate symptoms Anxiety or depression often detectable with careful history The location of angina pectoris is usually retrosternal; most patients do not localize the pain to any small area. The discomfort may radiate to the neck, jaw, teeth, arms, or shoulders, reflecting the common origin in the posterior horn of the spinal cord of sensory neurons supplying the heart and these areas. Some patients present with aching in sites of radiated pain as their only symptoms of ischemia. Occasional patients report epigastric distress with ischemic episodes. Less common is radiation to below the umbilicus or to the back. Stable angina pectoris usually develops gradually with exertion, emotional excitement, or after heavy meals. Rest or treatment with sublingual nitroglycerin typically leads to relief within several minutes. In contrast, pain that is fleeting (lasting only a few seconds) is rarely ischemic in origin. Similarly, pain that lasts for several hours is unlikely to represent angina, particularly if the patient's electrocardiogram (ECG) does not show evidence of ischemia. Anginal episodes can be precipitated by any physiologic or psychological stress that induces tachycardia. 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. . Chapter 013. Chest Discomfort (Part 2) Angina Pectoris (See also Chap. 237) The chest discomfort of myocardial ischemia is a visceral discomfort that is usually. intensity rather than quality. Table 13-2 Typical Clinical Features of Major Causes of Acute Chest Discomfort Condition Durati on Qualit y Location Associat ed Features Angina More than. visceral discomfort that is usually described as a heaviness, pressure, or squeezing (Table 13 -2). Other common adjectives for anginal pain are burning and aching. Some patients deny any "pain"