D.
DISCUSSION ON CARDINAL SYMPTOMS
CHEST PAIN
Chest pain is a common symptom of cardiac disease. It can be due to noncardiac causes such as
anxiety or diseases involving the respiratory, musculoskeletal or gastrointestinal systems.
Causes of Chest Pain (Fig. 4D.1)
Fig. 4D.1: Causes of chest pain.
Differential Diagnosis of Chest Pain (Table 4D.1)
Table 4D.1: Differential diagnosis of chest pain.
Potentially life- threatening causes Common nonlife- threatening causes
• Acute coronary syndromes: Acute myocardial • Gastrointestinal
infarction (MI), ST-segment elevation MI, non-ST- – Biliary colic
segment elevation MI – Gastroesophageal reflux disease
• Unstable angina – Peptic ulcer disease
• Pulmonary embolism • Pulmonary
• Aortic dissection – Pneumonia
• Myocarditis (most common cause of sudden – Pleuritis
death in the young)
• Musculoskeletal pain: Costochondritis (Tietze’s syndrome), intercostal
• Tension pneumothorax myalgia/neuralgia, fracture of the ribs (cough, trauma), secondaries in
• Acute chest syndrome/crisis in sickle cell anemia the ribs, Bornholm disease
• Pericarditis • Thoracic radiculopathy: Texidor’s twinge (precordial catch syndrome)
• Boerhaave’s syndrome (perforated esophagus) • Emotional: Anxiety
• Gastrointestinal: Perforated peptic ulcer, acute • Neural: Shingles/herpes zoster
pancreatitis, acute cholecystitis
Differential Features of Ischemic Cardiac and Noncardiac Pain (Table 4D.2)
Table 4D.2: Differential features of ischemic cardiac and noncardiac pain.
Features I schemic cardiac pain Noncardiac pain
Site Central, diffuse Peripheral, localized
Character of pain Tight, squeezing, dull, constricting, choking or ‘ heavy’ Sharp, stabbing, catching
Precipitation/provocation Exertion, emotion Spontaneous, not related to exertion
Radiation Jaw/neck/shoulder Usually no radiation
Relieving factors Rest (in less than 5 minutes), nitrates Not relieved by rest or by nitrates
Associated features Breathlessness, diaphoresis Depends on the cause
Differentiating Features of the Common Causes of Chest Pain (Table 4D.3)
Table 4D.3: Differentiating features of the common causes of chest pain.
Disease Description L ocation Radiation Associations
Acute coronary Crushing, Retrosternal, left Right (R) or left (L) Dyspnea, diaphoresis, nausea
syndromes tightening, anterior chest or shoulder, R or L
squeezing, or epigastric arm/hand/jaw
pressure like
Pulmonary Heaviness, Whole chest None Dyspnea, unstable vital signs, feeling of
embolism tightness (massive) or focal impending doom if massive or just
chest (segmental) tachycardia, tachypnea if segmental
Aortic dissection Ripping, tearing Midline, Interscapular area Secondary arterial branch occlusion
substernal of back (paraplegia)
Pericarditis/cardiac Sharp, constant or Substernal None Fever, dyspnea, pericardial friction rub
tamponade pleuritic
Pneumothorax Sudden, sharp, One side of chest Shoulder, back Dyspnea
lancinating,
pleuritic
Perforated Sudden, sharp, Substernal Back Dyspnea, diaphoresis, signs of sepsis
esophagus after forceful
vomiting
Types of angina
Angina Angina is a symptom of myocardial ischemia that is recognized clinically by its character, its location and its
relation to provocative stimuli
Stable angina Angina is stable when it is not a new symptom and when there is no deterioration in frequency, severity or
duration of episodes
Unstable angina This is a form of acute coronary syndrome. It has at least one of these three features:
1. It occurs at rest (or with minimal exertion), usually lasting more than 10 minutes
2. It is severe and of new onset (i.e. within the prior 4–6 weeks)
3. It occurs with a crescendo pattern (i.e. distinctly more severe, prolonged, or frequent than before)
Variant Caused due to coronary vasospasm
angina/prinzmetal
angina
Microvascular Angina-like chest pain in the context of normal epicardial coronary arteries on angiography
angina/cardiac
syndrome X
Episodic angina This syndrome is one in which pains having the characters of angina of effort occur at longer or shorter
intervals
Nocturnal angina Seen in severe aortic regurgitation (AR)
Proposed mechanisms are:
1. Prolonged diastole at night: Regurgitation time is prolonged
2. Dilated left ventricular (LV), increased LV mass, increased demand
3. Diastolic coronary stealing, Venturi effect of AR jet
Angina decubitus It is angina that occurs when a person is lying down (not necessarily only at night) without any apparent
cause. Occurs because gravity redistributes fluids in the body
Second wind, or Describes patients with ischemic heart disease and exertional angina that forces them to stop; after the first
warm up, angina bout of angina, they are able to continue with minor, or even without any, further symptoms ischemic
preconditioning and collateral recruitment are proposed mechanisms
Linked angina It is associated with:
1. Gastroesophageal and duodenal disorders and diseases
2. Gallbladder disease
3. Cervical spondylitis
Refractory angina Angina that cannot be controlled with optimal medical therapy and where revascularization is not feasible
Status anginosus It is a clinical term denoting periods of frequently recurring anginal pain at rest, indistinguishable from the
pain of cardiac infarction or from its prodromal manifestation, but without the electrocardiographic and
laboratory evidences of classical cardiac infarction
Vincent’s angina Fusospirochetal infection of the pharynx and palatine tonsils, causing “ulceromembranous pharyngitis and
tonsillitis”
Ludwig’s angina Severe diffuse cellulitis that presents as an acute onset and spreads rapidly, bilaterally affecting the
submandibular, sublingual, and submental spaces
Abdominal Postprandial pain that occurs in the mesenteric vascular occlusive disease
angina
Angina sine A painless episode of coronary insufficiency. It is associated with diabetes mellitus and also called silent
dolore ischemia
Canadian cardiovascular society (CSS) functional classification of angina
Class Ordinary activity (e.g. walking, climbing stairs at own pace) does not bring on angina. Angina occurs only with strenuous,
I rapid, or prolonged exertion at work or during recreation
Class Slight limitation of ordinary activity. Symptoms occur when walking or climbing stairs rapidly, walking up a hill, walking up
II stairs after a meal, in cold weather, in wind, or when under emotional stress, or only a few hours after waking, and
climbing more than one flight of ordinary stairs at a normal pace and in normal conditions
Class Marked limitation of ordinary activity. Symptoms occur after walking 50–100 yards on the level, or climbing more than one
III flight of ordinary stairs in normal conditions
Class Inability to carry on any physical activity without discomfort. Angina may be present at rest
IV
Angina Equivalents
These are commonly seen in elderly and diabetics (with autonomic neuropathy) where ischemic angina
is absent and they present with:
• Shortness of breath
• Perspiration/diaphoresis
• Syncope
• Gastrointestinal (GI) symptoms—upper abdominal pain, nausea, and vomiting
• Fatigue
• Confusion.
PALPITATIONS
Definition
Palpitation is the term used to describe an uncomfortable increased awareness of one’s own heartbeat
or the sensation of slow, rapid or irregular heart rhythms.
• Palpitations do not always indicate the presence of arrhythmia and conversely, an arrhythmia can
occur without palpitations.
• Palpitations are usually noted when the patient is quietly resting.
• Palpitation can be either intermittent or sustained and either regular or irregular.
• A change in the rate, rhythm or force of contraction can produce palpitations.
