Differential Diagnosis of Chest Pain

Differential Diagnosis of Chest Pain includes

1. Cardiac
a. Coronary artery disease (supported by ECG abnormalities-changes in the T waves, ST segments, or conduction pattern; not ruled out by a normal ECG), coronary artery embolism or dissection, coronary artery abnormalies.

Differential Diagnosis of Causes of Angina Besides Coronary Artery Disease

There are othe cardiac causes of angina besides coronary artery disease:

A. Congenital anomalies of the coronary arteries can take many forms. Their prevalence is 1% to 2% of the general population. Anomalous origin of the left or right coronary artery from the contralateral sinus of valsava with passage between the aorta and pulmonary artery may produce ischemia and is associated with sudden death.

Stable Angina

           Chronic Stable Angina is the initial manifestations of Ischemic Heart Disease in approximately half of patients with Coronary Artery Disease, Approxymately 15 millions American have CAD. Despite the well-documented decline in cardiovascular mortality, Ischemic Heart Disease remains the leading single cause of death in The United States and is reponsible for nearly one of every five deaths.

Late Complications of Myocardial Infarction

           Postinfarction complication rates have fallen dramatically since the advent of early reperfusion strategies. Nevertherles, many patients (large infarction, silent infarction, late presentation, delayed or incomplete reperfusion) remain at high-risk for life-threatening late complications of myocardial infarction. The role of an urgent beside echocardiogram for a rapid diagnosis cannot be overemphasized. The mnemonic "FEAR A MI" is a logical way to remember and respect these potentially life-threatening complication while caring for a patient in the ICU, as demontrated below:

Symptomatic Tachycardia in Cardiovascular Emergencies

      Patients who are pulseless or clinically unsable with the tachycardia require immediet defibrillation  with unsynchronized high-energy shocks (200, 300, 360 Joule) followed by appropriate ABC attention of ACLS. The cardiac rhythm is briefly assessed between shocks.

Symptomatic Bradycardia in Cardiovascular Emergencies

          Bradycardia in Cardiovascular Emergencies is when heart rate < 60 beats per minute and inadequate for clinical condition. So what would you do as a Doctor or paramedic to treat this condition? There are step which must done: SSSSSlow

Cardiac Tamponade

Cardiac tamponade occurs with an increase in intrapericardial pressure due to a pericardial effusion, which is characterized by

               1. Elevation of intrapericardial pressure

               2. Limitation of Right Ventricle Diastolic Filling

               3. Reduction of Stroke Volume and Cardiac Output.

The presence of a pericardial effusion does not necessarily mean tamponade physiology is present.

Cardiogenic Shock

Patients with the highest immediate mortality (>50%) are those with cardiogenic shock: a low-output state with signs and symptoms of organ underperfusion.

Hypertensive Emergency

Hypertensive crises should be differentiated into Hypertensive emergency or urgency, based on evidence of end-organ damage. Severe hypertensiion specifically affects the renal (elevated serum creatinin, hematuria (angina, heart failure, aortic dissection), and neurologic (headache, mental status changes), cardiovascular

How to Make Diagnosis of Heart Failure

History or Anamnesis

              There are three primary objectives of the history when interviewing a patient with Heart Failure:

           1. Identify etiology of Heart Failure

           2. Asses progression and severity of illness

           3. Assess volume status

Etiology of Heart Failure

           There are many causes of myocardial injury that can result in clinically apparent Heart Failure. However, in considering the etiology of cardiac dysfunction it is useful to subdivide patients into those with abnormal systolic function and those with preserved systolic function. Among patients with abnormal systolic function, defined as ejection fraction < 40%, approximately two thirds will have an ischemic cardiomyopathy (ICM), usually resulting from prior myocardial infarction (MI).

Heart Failure

             Heart failure is one of the fastest-growing, cardiovascular diagnose in the United States, where therea re over 1 million hospitalizations for heart failure annually, at a cost exceeding $33 billion. Despite significant advancements in the management of Heart Failure, the mortality remains high; once a patient is hospitalized for Heart failure, the 1 - and 5 - years death are 30% and 50% respectively, In order to improve HF outcomes and reduce hospitalizations, physicians must be able to identify these patients early in their disease and initiate appropiate lifesaving and symptom-reducing therapies.

Diagnosis and Treatment for Chest Pain

Diagnosis Testing

         The ECG is critical to the evaluation of chest pain. In fact, for the acutely ill patient, it is prudent to quickly review the ECG prior to completing the history and physical. ECG findings that should not be missed are outlined in Table A. Prior ECGs for comparison are invaluable. If ischemia is a concern. serial ECGs are useful to look for evolution of the infarct pattern. Suspicion for right ventricular infarct should be investigated with right-sided precordial leads, and suspicion for a posterior infarct should prompt evaluation with posterior chest leads.

Physical Examination for Chest Pain

                A history-directed physical exam is not a full physical exam. Base on information obtained in the history, the directed exam should confirm a suspected diagnosis or narrow a differential diagnosis list. Much like the focused history, a directed exam should rapidly and accurately characterize the cest pain and screen for life-threatening findings. Most of the few minutes spent examining the patient should be focused on the cardiovascular and pulmonary exams. Clinical pearls for a chest pain-directed exam listed  below

Evaluation of Chest Pain

            Chest pain is the chief complaint for 5% to 10% of all emergency department visits in the United States and  represents a wide spectrum of disease, from benign to life-threatening conditions. Consequently the initial evaluation must rapidly focus on ruling out the five most common life-threatening conditions that present with chest pain:

Pathogenesis of Acute Coronary Syndrome part 2

         Recent pathogenesis explains acute coronary syndrome, acute coronary syndrome (ACS) is caused by obstruction and thrombotic occlusion of the coronary arteries, which is caused by a vulnerable atherosclerotic plaque erosion, fissure, or rupture. The main cause of acute coronary syndrome triggered by erosion, fissure, or rupture of atherosclerotic plaques is due to the presence of the condition of unstable atherosclerotic plaques (vulnerable atherosclerotic plaques) with characteristics; substantial lipid core, thin fibrous cups, and the plaque shoulder (shoulder region of the plague) full the activity of inflammatory cells such as T lymphocytes and others (Figure A). Thick plaque that can be seen with the percentage of narrowing of the coronary arteries on coronary angiography examination does not mean anything as long as the plaque in stable condition. In other words, the risk of plaque rupture in atherosclerosis is not determined by the amount of plaque (degree of constriction) but by vulnerability (vulnerability) plaques.

Pathogenesis of Acute Coronary Syndrome part 1

       Acute Coronary Syndrome is one of the clinical manifestations of coronary heart disease is mainly caused by the addition of the further atherothrombotic ischemic stroke, and peripheral arterial disease (PAD). Further atherothrombotic is a chronic disease with a very complex process and multifactorial and interrelated.

Clinical Features of Coronary Heart Disease

1. Clinical features of coronary heart disease:
Several days or weeks before the body was not powered, chest discomfort, heart beating fast when sports or move, gasping for breath, sometimes accompanied by nausea, vomiting and body secretes more sweat.

Coronary Heart Disease Risk Factors

There are factors which can cause or trigger Coronary Heart Disease:

1. Lipid
        Dyslipidemia believed to be the major risk factors that can be modified for the development and progressive changes in the occurrence of coronary heart disease. Cholesterol is transported in the blood in the form of lipoproteins, 75% is a low-density lipoprotein (low density liproprotein / LDL) and 20% is a high density lipoproteins (high density liproprotein / HDL). HDL-cholesterol was lower has a good role in coronary heart disease and there is an inverse relationship between HDL levels and the incidence of coronary heart disease.

Causes of Coronary Heart Disease

       Coronary heart disease is caused by a buildup of fat in the blood vessel walls in the heart (coronary arteries), and this is gradually followed by various processes such as accumulation of connective tissue, calcification, blood clots that everything will narrow or clog the blood vessels. This will result in the area of heart muscle is deprived of blood flow and can lead to many serious consequences of angina pectoris (chest pain) to heart infarction, which is known in the community with a heart attack that can lead to sudden death.

What Coronary Heart Disease is

      Coronary heart disease (CHD) or ischemic heart disease is heart disease arising from coronary artery narrowing on. The narrowing of atherosclerosis can be attributed, among others, various types of arteritis, coronary embolism, and spasm. Coronary Heart Disease (CHD) is the imbalance between the needs of the heart and supply blood perfusion by coronary artery oxygenited

Heart Anatomy

       The heart is located in the thoracic cavity, around the center line between the sternum and vertebrae anterior to the posterior side. The heart has a wide base at the top and tapered to form the bottom end is called the apex. When the heart beats (contractions) are strong, hit the apex of the chest wall on the left. The fact that the heart is located between the two structures, namely the sternum and vertebrae bones, used as part of cardiopulmonary resuscitation on the rescue action.