It is often worse upon lying down and improved with sitting. Low-risk patients without evidence of MI are evaluated with exercise or pharmacologic stress testing, as indicated. Higher-risk patients or those with STsegment elevations undergo urgent cardiac catheterization. Cocaine use can cause chest pain and ST-segment changes due to vasospasm, even in patients without significant occlusive coronary artery disease, and may result in myocardial injury.
Pericarditis is characterized by sudden onset of sharp, stabbing, substernal chest pain with radiation along the trapezius ridge. Often, the pain is worse with inspiration and lying flat and is alleviated with sitting and leaning forward.
Given the ephemeral nature of the friction rub, its absence does not rule out pericarditis. The classic rub consists of three components: occurring during atrial systole, ventricular systole, and ventricular diastole. An echocardiogram may be helpful if there is suspicion of significant pericardial effusion or pericardial tamponade. Acute pericarditis secondary to infection viral or bacterial may be preceded or accompanied by symptoms of an upper respiratory tract infection and fever.
In patients with acute pericarditis, hospitalization is prompted by an associated MI, pyogenic infection, or tamponade. Outpatient management is appropriate if other potentially serious causes of chest pain are excluded, hemodynamic status is normal, and a moderate or large pericardial effusion is excluded by echocardiography.
In the absence of a specific cause for acute peri-. Although dissection is fairly rare compared to other chest pain causes an incidence of 3 per , patients per year , it can be rapidly life threatening. An early diastolic murmur due to acute aortic insufficiency may be heard, particularly if the dissection involves the ascending aorta, but the presence or absence of a diastolic murmur is not useful in ruling in or ruling out dissection.
When aortic dissection is suspected, imaging the aorta is indicated. Because of an increased risk of coronary artery dissection and tamponade with dissection progression, dissections involving the ascending aorta and.
Figure 1. Electrocardiogram showing sinus rhythm with diffuse ST-segment elevation consistent with acute pericarditis. Aortic stenosis is a cause of exertional chest pain and may also be accompanied by dyspnea, palpitations, and exertional syncope due to a diminished cardiac output see Chapter 9. Physical examination reveals a systolic, crescendo-decrescendo murmur best heard at the second right intercostal space, with radiation to the right carotid artery.
A transthoracic echocardiogram is the diagnostic test of choice for patients with suspected aortic stenosis. Patients with spontaneous esophageal rupture typically have severe retching and vomiting followed by excruciating retrosternal chest and upper abdominal pain.
These symptoms are followed by the rapid development of odynophagia, tachypnea, dyspnea, cyanosis, fever, and shock. Many cases are related to excessive alcohol ingestion.
Chest radiography may show pneumomediastinum, although computed tomography is more sensitive for making this diagnosis. Age rating For all ages. This app can Access all your files, peripheral devices, apps, programs and registry Access your Internet connection Microsoft. Permissions info. Installation Get this app while signed in to your Microsoft account and install on up to ten Windows 10 devices.
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