A. Trauma

1. Sprain of the chest wall muscles and ribs, from heavy lifting , pulling and other strenuous activities.

2. Blunt trauma to chest wall including rib bruise, or fracture.

B. Anxiety and tension causing muscle spasms of chest wall are the most common causes of chest pain,especially under the left breast,which is nonradiating,lasting a few seconds to days.It may coexit with angina pectoris (see figure 70).

C. Radicular pain into the chest wall from irritated nerves,which innervate the chest wall, i.e. arthritis, herniated disc in the cervical and thoracic spines.

D. Inflammation of rib,cartilage junctions in the front of the chest,especially close to the left sternum (i.e. Tietz's syndrome).

Also, shingles due to herpes zoster infection of the thoracic nerves may be a cause of chest pain.

E. Inflammation of the stomach,duodenum,esophagus and gall bladder can cause chest pain.
To go further, pain originating in the gastrointestinal tract, especially in the esophagus,is commonly confused with ischemic chest pain due tocoronary heart disease. Diffuse esophageal spasm with pain behind the sternum associated with swallowing. Also reflux esophagitis due to regurgitation of the stomach's acid content into the esophagus can cause high epigastric or retrosternal "heartburn" pain after meals, coffee etc. Esophagoscopy etc may be necessary to diagnose the condition. In addition,peptic ulcers and gall bladder diseases (biliary colic) may be confused with chest pain of cardic origin.

F. Inflammation of the pleurae (thin sheets of tissue covering the lungs and inner chest wall) of the lungs(pleuritis)can cause chest pain,especially when taking a deep breath.

G. Inflammation of the bronchial tubes(bronchitis) and pneumonia can cause chest pain.

H. Chest pain due to coronary atherosclerotic heart disease (see figure 70) has specific characteristics,and occurs when the coronary blood flow is not adequate to supply enough oxygen for the activity currently being performed,while it is sufficient when the patient is at rest.Spasm or thrombosis in the coronary artery can impede blood flow to cause the chest pain,which is brief and is called angina pectoris.

1. It can be described variously as an aching ,a heavy feeling, chest pressure, chest tightness, indigestion in chest, or a squeezing in the chest.

2. It can occur with exertion or rest, or when one lies down,orgets up in the morning, as well as with emotions, after meals or exposure to cold.

3. It may be under the sternum of the chest or across the front (upper part) of the chest, affecting an area the size of a clenched wist.

4. It can radiate into the neck, tongue ,jaw,palate, left arm, right arm, elbow, wrist, upper back or abdomen.

5. It usually lasts for 1 to 3mins. If the provoking cause is discontinued(like walking too fast). Anger may cause the pain to last 10 mins.

6. The pain is promptly relieved by putting nitroglycerine under the tongue.

7. The recognition of angina pectoris is strengthened when the pain is reproducible and when a specified degree of effort produces the discomfort.

I. Anterior chest,excruciating pain may be due to a rupture or dissection of the walls of the great vessel(aorta,see figure 51c,51d,51e) coming out of the heart.The pain may last hours and is often of maximal intensity at the onset,radiating into the back of the chest.

J. Pain due to an inflammation of the covering of the heart(pericardium)called acute pericarditis(see figures 27,104a,104b)is not related to effort and is aggravated by breathing,located over the left chest and may radiate to the neck and shoulders.It may be aggravated by turning the body from side to side,while leaning forward may relieve it.

K. Blood clots from other parts of the body may go to the lungs(called pulmonary emboli) and cause no chest pain . If there is pain, it may mimic angina pectoris or pleurisy, aggravated by breathing.

 

A. Definitely consult a family , primary care, internist or cardiologist as soon as possible on an urgent basis to determine the exact cause of the chest pain to exclude a pending heart attack.

B. Depending on the severity ,duration,and frequency of the chest pain and associated history and symptoms ,it may be advisable to consult the emergency room physician immediately ,going if nessary by the 911 ambulance to diagnose whether a heart attack is imminent. Electrocardiogram(see figure94), chest x'ray and blood tests will need to be done in the work up.

 

There are many causes of dyspnea including the following:

a. Heart failure (acute or chronic ,see definition)

b. Lung disease such as asthma and emphysema from chronic cigarette smoking

c . Anxiety

d. Obesity

e. Poor physical conditioning

f. Fluid in the pleural space between the lungs and chest wall(pleural effusion)

g. Blood clots(emboli) to lungs

h. Pneumonia

i. Rupture of a small segment of the lung (i.e. a bleb representing distended, ruptured alveolae and septae as in emphysema) allowing inhaled air to escape into the enclosed potential space between the lung and the chest wall (pleural cavity) leading to lung collapse (pneumothorax) due to the intrapleural pressure against the lung and heart.

Dyspnea of recent onset may signify recent heart failure or angina pectoris, rather than chronic lung disease

 

It may be due to lung (bronchial asthma) or heart disease (cardiac asthma) or both.

It is a form of dyspnea in which breathing is less difficult sitting up in bed rather than being recumbent

It may be due to heart failure or chronic lung disease.

 

Palpitations is a disagreeable awareness of the heart beat,often described as a pounding, stopping, jumping, or racing in the chest.

The sensitivity of the nervous system determines whether or not the patient complains of palpitations, which are not related to the seriousness of the heart disease or the type of arrhythmia.

When patients have a premature heart contraction(see figure94b ), they feel the post-extrasystolic beat,associated with a large stroke volume,which is due to the longer filling period in diastole. A patient may be aware of a cardiac arrhythmia(see figures 3, 5a, 7,14, 16) by detecting an uncomfortable sensation in the neck. They may complain when the heart beat is slow or fast, and when it regular or irregular.

 

Heart syncope is the transient loss of consciousness due to an inadequate brain blood flow secondary to an abrupt decrease in cardiac output.

Syncope may occur in many types of heart disease and circulatory disorders (see Table1. Causes of syncope).

Reference:Kapoor,W.N.,The New England Journal of Medicine,v343,n25,12/21/00,pp1856-1862

Reference:Kapoor,W.N.,The New England Journal of Medicine,v343,n25,12/21/00,pp1856-1862

There are certain types of syncope that can be characterized as postural hypotension, carotid sinus syncope, vasovagal and vasodepressor syncope,cough syncope and urination syncope.

Bilateral carotid artery stenosis and vertebral artery obstruction may cause syncope.
See table 2 for clinical features suggestive of specific causes of syncope.

Reference:Kapoor,W.N.,The New England Journal of Medicine,v343,n25,12/21/00,pp1856-1862

Diagnosing the Cause of Syncope Include the Following Procedures:

1. History and Physical Examination

2. Electrocardiogram(see figure94),which may lead to immediate treatment of underlying condition(e.g.the implantation of a pacemaker in complete heart block,see definition of atrioventricular disturbances and figures 84-92),or can help plan further testing.

3. If initial assessment leads to a diagnosis(i.e.vasovagal syncope,situational syncope,drug-induced syncope,complete heartblock) further tests may be planned(e.g.determining the cause of postural hypotension) and therapy started.

4. See table for a list of clues to specific diagnoses.

Reference:Kapoor,W.N.,The New England Journal of Medicine,v343,n25,12/21/00,pp1856-186

The electrocardiogram may show

1. signs of ischemia(abnormal shifts of the ST segment of the EKG after the QRS complex inscription in a downward direction below the baseline compared to the ST segment prior to the onset of the QRS,see figure 94 for normal EKG)

2. a long QT interval(see figure 94 for normal EKG),siginifying an aquired or inherited repolarization disorder(see definition of types of arrhythmias as to causes),which can predispose to ventricular tachycardia(see figures 6,7,8,9a,9b)with syncope ,possibly treatable with radiofrequency catheter ablation,

Zipes,D.P.MD,Clinical Application of the Electrocardiogram,Journal of the American College of Cardiology ,v.36.n6,2000,pp1746-8

3. a bundle branch block(suggesting a dilated or hypertrophic type of cardiomyopathy(see figures 39f,39g,40a,40b 4of )or even an arrhythmogenic right ventricular or muscular dystrophy one).

Zipes,D.P.MD,Clinical Application of the Electrocardiogram,Journal of the American College of Cardiology ,v.36.n6,2000,pp1746-8

4. Also, there are two types of ventricular tachycardias, which occur in apparently normally structured hearts and include

a. those originating in the right ventricular outflow tract that have a LBBB-inferior axis morphology,

b. those coming from the left ventricular septum that have a RBBB and a left axis deviation contour.

c. Both are relatively easy eliminated with radiofrequency catheter ablation(see figure11).

Zipes,D.P.MD,Clinical Application of the Electrocardiogram,Journal of the American College of Cardiology ,v.36.n6,2000,pp1746-8

Specific tests like an echocardiogram or cardiac catheterization for aortic stenosis(see definition of aortic stenosis,and figures 46a-c,47)may be necessary.

5. If the above tests are unrevealing,the patient has unexplained syncope .

6. In patients with structural heart disease ,the chief concern is arrhythmias (see definition of arrhythmias; see figures 1, 2, 3, 5a,7,14,16 )

7. Echocardiography( see definition),

8. Stress testing(see definition),

9. 24 hours Holter electrocardiographic(EKG) monitoring(see definition)with symptoms compared to the time of the arrhythmia discovered,

10. Cardiac consultation may be in order,as well as cardiac electrophysiology, if the Holter EKG monitoring is unrevealing.

11. If the electrophysiologic studies are negative,then continuous loop monitoring for bradyarrhythmia(see figure 16)is recommended, since the sensitivity for these arrhyhmias are low for electrophysiologic tests.

Reference:Kapoor,W.N.,The New England Journal of Medicine,v343,n25,12/21/00,pp1856-1862

12. Continuous loop monitors are used for long term monitoring lasting weeks to months.The patient or an observer can activate the monitor after symptoms occur, thereby freezing in its memory the readings from the previous 2 to 5 minutes and the subsequent 60 seconds.

13. Patients with recurrent syncope and negative electrophysiology studies should be evaluated for neurally mediated syndrome(i.e.carotid sinus syndrome,psychiatric illnesses),including tilt testing, which will provoke vasovagal syncope in susceptible persons.

14. An electroencephalogram may be useful if a seizure is suspected ,or there is a history o f convulsions.

15. Hospitalization for rapid identification of the cause of syncope is advised if potential adverse consequences are high if evaluation is delayed, and for treatment (i.e. aortic stenosis,HCM figures39f,39g,40a,4 0b 40f,63,64).

Reference:Kapoor,W.N.,The New England Journal of Medicine,v343,n25,12/21/00,pp1856-1862

16. Patients with structural heart disease,ischemia(see figure70), abnormal EKG,and arrhythmias , adverse drug reactions and severe orthostasis should be hospitalized for diagnostic evaluation

TREATMENT

1. In neurally mediated syncope atenolol has been helpful as has paroxetine.

2. Permanent pacemakers providing rapid pacing below a predetermined drop in heart rate in patients with severe symptoms and bradycardia on tilt tests showed a reduction in rate of syncope(see figure12).

Reference:Kapoor,W.N.,The New England Journal of Medicine,v343,n25,12/21/00,pp1856-1862

3. Volume replacement in orthostatic hypotension should be included if there is intravascular depletion and any drugs responsible reduced in dose.

4. In autonomic failure(see definition of autonomic nervous system and figure 28) increase in salt and fluid intake, use of waist high stockings, abdominal binders, and fludrocortisone are beneficial as well as midodrine.