Stable angina is caused by atherosclerotic changes in the coronary arteries.

may be precipitated by physical activity, emotional stress, or eating a heavy meal. The pain associated with stable angina has similar characteristics (severity, duration, precipitating events) each time it occurs. Stable angina attacks usually last less than 5 minutes and are relieved by rest and/or nitroglycerin.

Risk factors associated with stable angina include:

^age, HLD, HTN, DM, being a fatso, smoking

Syndrome X

Coronary microvascular dysfunction (improper function of tiny blood vessels)

Unstable angina is an acute coronary syndrome (ACS), commonly caused by the rupture of atherosclerotic plaque.

new onset angina

stable angina which becomes more frequent

rest angina

unstable angina s/sx

symptoms worsen in severity, duration, and quality

attacks may last as long as 30 minutes, and may or may not be relieved by rest or nitroglycerin

could be s/sx of MI

Prinzmetal's angina, or variant angina, is a less common form of angina caused by coronary vasospasm.

Variant angina may be severe in intensity, often occurs at rest during the early morning hours, and is relieved with nitroglycerin.

myocardial infarction (MI)

Chest pain that is associated with a change in cardiac biomarkers and evidence of ischemia

Myocardial infarction is due to the rupture of atherosclerotic plaque and subsequent thrombus formation. The pain associated with Type 1 myocardial infarction (MI) is similar to the pain associated with angina but is usually more severe.

MI s/sx

pain is a heaviness like "an elephant sitting on my chest," pressure, burning, constriction, or squeezing. Other common clinical manifestations often associated with Type 1 MI pain include shortness of breath, sweating, weakness, nausea, vomiting, and severe anxiety.

Myocardial infarction pain:

Usually has a sudden onset

Lasts longer than 30 minutes

Is not relieved by rest

Is not relieved by single doses of sublingual nitroglycerin

B.C. is brought in complaining of squeezing chest pain. In your assessment of him, you learn that this is the second incident of this type he has experienced. The first incident occurred when he was running 2 days ago. He says the pain was excruciating but went away after rest. In both instances, the type of pain has been the same, and it lasted between 5 and 10 minutes. B.C. is worried that he has had a heart attack.

unstable angina. The pain is new onset, is less than 30 minutes in duration, and is relieved by rest.

Acute Coronary Syndrome (ACS) includes unstable angina and non-Q wave and Q wave myocardial infarction.

The pathophysiology of ACS includes atherosclerosis, vasospasm, and thrombosis, which results in myocardial ischemia.

Pericarditis is an inflammation of the pericardium that can occur as a result of a viral infection, TB, radiation, or following myocardial infarction.

pain associated with pericarditis usually begins over the sternum and may radiate to the back and subscapular area. Occasionally the pain radiates to the shoulders and arms and can be confused with the pain of angina or myocardial infarction. Likely to have a fever.

Chest pain associated with pericarditis has the following characteristics:

The pain is usually described as sharp, stabbing, and knifelike.

This type of pain can range from moderate to severe.

The pain may last anywhere from many hours to many days.

The pain is aggravated by deep breathing, and varies with position.

This type of pain is often relieved by sitting up and leaning forward.

Pericardial friction rub may be present.

Chest Pain: Dissecting Aortic Aneurysm

usually from chest trauma or uncontrolled HTN

Aortic dissection can lead to myocardial infarction or stroke. It is a life-threatening condition that requires emergency medical attention.

usually located in the anterior portion of the chest and radiates to the thoracic area of the back.

Sudden, severe anterior chest pain, which may last for hours to days

The pain is described like "tearing," "ripping," or "knifelike."

The location of the pain shifts as the dissection extends.

The pain seems to be unrelated to any precipitating factors and is usually not relieved by any conventional measures.

Difference in systolic pressure between arms

Absent pulses

Paralysis or other neurological deficits

An early diastolic murmur of aortic insufficiency/regurgitation

Pulsus paradoxus

Stridor

Dissecting aortic aneurysm

Splitting of the aortic wall by blood entering through an internal tear or by interstitial hemorrhage

stridor

A raspy inhalation caused by a constricted airway

Chest Pain: Mitral Valve Prolapse

Abnormalities of the mitral valve, which cause it to prolapse backward into the left atrium during systole, can also be a source of chest pain.

often no symptoms but can include:

An onset that is gradual and mild

Pain described as sharp or vague

Pain occurring in paroxysmal episodes, which may be brief or prolonged

Pain that is usually unrelated to exertion and unrelieved by sublingual nitroglycerin or rest

Rarely radiates to the jaw, back or arms

Pain is positional; decreased when lying down

May also include:

• Palpitations
• Dizziness
• Syncope related to dysrhythmias
• Dyspnea
• A late systolic or pansystolic murmur
• Fatigue or decreased exercise tolerance
• Anxiety
• Headaches and mood swings

Paroxysmal

Occurs briefly and transiently

Pansystolic

A kind of murmur that occurs during the entire systole

Chest pain from coronary insufficiency (angina) usually lasts less than 15 minutes.

true

Chest pain from myocardial infarction can be relieved by rest and by single doses of sublingual nitroglycerin.

false

What measures can be taken to relieve chest pain associated with pericarditis?

Sitting up and leaning forward

Which of the following clinical manifestations are associated with mitral valve prolapse?

Vague substernal chest pain

Scenario

Mrs. S., a 56-year-old woman, was admitted to the medical-surgical unit after experiencing chest pain, nausea, and dizziness. She denies any significant past medical history and states that her only problem is an occasional cough. She has smoked one pack of cigarettes per day for 30 years. She says that she hasn't needed to see a physician in over 10 years because she just hasn't been sick. She describes the pain as a funny feeling in her chest. She denies that the pain occurred with activity, and it is only slightly relieved by sublingual nitroglycerin. Mrs. S. is admitted with nasal oxygen at 2 L/min. Her pulse oximeter reading was 92% on room air but improved to 95% after the nasal oxygen was administered.

To detect evolving signs of myocardial ischemia and infarction

various types of pain, which include:

• Visceral
• Somatic
• Cardiac
• Nociceptive

nociceptive

Pain in the chest region is mostly induced by mechanical, chemical, or thermal means, and is considered to be nociceptive.

Visceral pain

Described as aching or heaviness and is generalized. The pain receptors in the viscera react to stretch, inflammation, and ischemia. Visceral pain originates in specific organs such as the heart, liver, bowels, or bladder. Examples include chest heaviness or crushing.

Somatic pain

The pain is described as sharp, piercing, and specific to a local area. The pain is reproducible with palpation. An example includes costochondritis.

Cardiac pain

Pain is a sharp and localized pain in the chest region. It may be visceral and somatic or neither. It may also be referred pain. Examples include a patient with MI who only feels gastric fullness or heaviness in the chest.

Nociceptive pain

Nociceptive pain arises from specific pain receptors and is classified as somatic or visceral in nature.

Quality

Sharp or dull pressure?

Location

Where is the pain radiating?

Duration

When did the pain start and stop?

Intensity

How would you describe the pain on a pain scale?

Accompanying symptoms

Did the pain occur in isolation or with other symptoms?

Aggravating and alleviating factors

What makes the pain better or worse?

assess the patient for ischemic causes of chest pain by asking about:

• Any history of angina or MI
• The patient's age (Risk increases with age. MI is more common in men after age 40 and women after age 50.)
• Additional risk factors (smoking, hypertension, hyperlipidemia, or diabetes)

Woman difference

Fatigue, tiredness, and sleep disturbances may be symptoms of coronary artery disease in women

visceral pain

aching or heaviness

crushing type pain

somatic pain

sharp and piercing

costochondritis

nociceptive pain

somatic or visceral pain

mechanical, thermal, or chemical

cardiac pain

visceral and cardiac component

sharp localized pain

The respiratory, or pulmonary, system is the second most common system involved in chest pain. Pulmonary disorders that cause chest pain include:

• Pulmonary embolism
• Pulmonary hypertension
• Spontaneous pneumothorax
• Pneumonia with pleurisy

pulmonary embolism

Not often causes pain. If so, usually described as a sharp, pleuritic pain. However, it may also be described as a dull, heavy sensation, that mimics anginal pain.

acute onset, aggravated by coughing or deep breathing

Dyspnea (the most common symptom)

Tachycardia

Tachypnea (the most frequent sign)

Anxiousness, restlessness, feeling "terrible"

Syncope

Hypotension

Low-grade fever

Elevated jugular venous pressure

Pleural rub

Hemoptysis

Embolus

A clot or other blockage that is carried by the bloodstream from its point of origin to a smaller blood vessel where it obstructs the circulation

Hemoptysis

Coughing up blood or blood in the sputum

Pulmonary hypertension is a disorder in which the blood pressure in the pulmonary arteries is abnormally elevated.

In the early stages, symptoms may be absent or subtle. As the disease progresses, shortness of breath is the most common symptom. Other symptoms include:

• Lightheadedness
• Fatigue
• Chest pain

A diagnosis of primary pulmonary hypertension

requires a battery of diagnostic testing to differentiate it from other causes of dyspnea.

pneumothorax is a collection of air or gas in the intrapleural space that causes the lung to collapse. A spontaneous pneumothorax occurs in the absence of trauma or injury.

Chest pain that is associated with spontaneous pneumothorax and is unilateral, located on the affected side.

• Dull, sharp, or stabbing pain that is very localized
• sudden onset and often lasts many hours
• Increases in intensity when taking deep breaths or coughing
• dyspnea, hyperresonance over the affected area, and decreased breath and voice sounds over the affected lung.
• Dx is CXR

Hyperresonance

An increased resonance produced when the area is percussed

Pleurisy

inflammation of the pleura, the membrane that surrounds the lungs. Pleurisy is a potential complication of pneumonia.

Chest pain due to pneumonia with pleurisy

Usually described as moderate in severity. The pain is worsened with deep inspiration or coughing and is usually relieved by holding your breath or applying pressure over the localized area of pain.

Dyspnea

Cough productive of bloody or foul-smelling sputum

Dull-to-flat percussion over areas of consolidation

Fever

Bronchial breathing patterns

Crackles

Pleural friction rub may be heard.

Chest pain causes by pneumonia with pleurisy is pleuritic in nature.

true

Pleurisy is an inflammation of the dura, surrounding the lungs.

false

A clinical manifestation of pneumonia with pleurisy includes yellow sputum.

false

Clinical manifestations of pneumonia with pleurisy include a pleural friction rub.

true

Chest pain due to pneumonia with pleurisy is worsened with deep expiration.

false