to learn more >> chest pain
You had a pain in your chest while you were anxious and you were working in the office under stress and your boss scolded you for going faster. You did not notice, you thought it was a gastric ulcer, because you had taken your fourth coffee and smoked your tenth cigarette.
But once you got home the pain persisted and you felt tired and nauseous. You did not go to the emergency room because you thought you had to do an endless row and you gave up and did not say anything to your wife not to alarm your family. But you were wrong!
Never underestimate this symptom!
I remember a friend of mine, a woman, who worked impeccably like a train (!) She at 50 years old had a sudden death at work! Do not make spells, do not touch amulets in your pockets!
Call your cardiologist, becuse it could be an angina.
Remember that today we are talking about >> Acute coronary syndrome and we
mean acute ischemic heart disease, which manifests itself as
>> SCA STEMI and >> SCA NSTEMI.
Remember that in order to diagnose ischemic heart disease there are non-invasive
or minimally invasive instrumental tests, such as ergometric tests or myocardial
perfusion scintigraphy.
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The prompt recognition of chest pain caused by heart disease is important from a
diagnostic and therapeutic point of view. Coronary artery disease is the most
common etiological factor. The various theories on the pathophysiology of this
pain have been reviewed by Gorlin.
Chest pain due to coronary artery disease represents a spectrum of various
morbid entities in which angina is at one extremity and myocardial infarction at
the other. Between the two morbid forms there are some less well-defined
entities such as coronary insufficiency, angina, pre-infarct angina and angina
pectoris variants. Exact knowledge of these different forms will be useful for
therapeutic purposes.
The term angina pectoris was introduced by Heberden in 1768 and with it was
intended to describe a sensation of strangulation (angina) and anxiety. A more
recent definition by Friedberg describes >> angina pectoris as a clinical
syndrome characterized by paroxysmal attacks of a frank pain or oppression,
usually located in the retrosternal, radiating most often to the precordium and
the left arm and sometimes to other adjacent areas, triggered by an effort or
emotion, and often also by other factors, and rapidly reduced by rest and
nitrate intake.
The triggering events and methods to reduce pain are the most important elements
for the diagnosis of angina pectoris. Any pain that is characteristically
triggered by physical exertion and cold and which resolves quickly with rest or
with the intake of nitroglycerin should be considered as an angina pectoris.
While most doctors know well the typical clinical picture of angina pectoris,
particular difficulties present its variants.
Pain can be superficial or deep and localized in almost every area of the
chest. It can originate at the level of the neck, jaw, cheeks, mastoid,
shoulders, high or low portion of the arms, hands or epigastrium or even radiate
in these areas.
It must be remembered that pain in the more typical retrosternal region with
irradiation to the left arm is often found in patients with a syndrome on a
purely functional basis.
The typical stress angina pectoris is usually mild at first and becomes
progressively stronger, until the patient is obliged to rest.
However, Prinzmetal has described a variant of angina pectoris in which the pain
develops characteristically at rest and, in fact, in these cases the patient can
usually face a certain effort without complaining of disturbances.
Night angina pectoris is not associated with physical exertion, but is
considered in connection with the emotions associated with dreams or with a
slight state of congestive decompensation. Non-frequent cases of urination
angina and decubitus angina have also been reported.
Angina is often triggered by exposure to cold. It is believed that a cold
environment evokes an increase in peripheral resistance which in turn leads to
an increase in cardiac work and oxygen consumption. What other triggering cause
of angina should not be neglected the very humid environment. Listening to the
heart can be useful for the diagnosis of angina pectoris.Indagini e semeioticaAn
added IV tone can be found frequently during an episode of pain and may
disappear once the pain has resolved. The IV tone canter is not specific for
coronary artery disease and only signifies a reduction in ventricular relaxation.
The usefulness of this finding lies in the transitory nature of the gallop and
its relationship with chest pain.
Similarly, a transient noise of mitral insufficiency attributable to a
dysfunction of the papillary muscle has the same diagnostic significance.
Paradoxical II-tone doubling has also been reported during angina pectoris.
The response to nitroglycerin is important in the diagnosis of angina. In this
sense it is necessary to keep in mind, in addition to the disappearance of pain,
the time necessary for the response to be made. If a relief is recorded 10
minutes or more after nitroglycerin intake it is likely that the effect is not
related to this drug.
The power of nitroglycerine must always be kept in mind, as a patient with
angina may have a negative response to nitroglycerine if the tablets have lost
power. For this purpose, to ascertain the power of the drug, it may be useful to
describe the patient's typical feeling of warmth and redness in the face once
the drug is taken. A simple maneuver can be useful to confirm a diagnosis of
angina pectoris. Levine described the massage of the carotid sinus, inducing a
sinus bradycardia, as a means of relieving angina.
With this procedure there is no disappearance of the secondary pain due to
changes in the spine or digestive tract. Between angina pectoris and myocardial
infarction are the intermediate syndromes, acute coronary insufficiency, anginal
state and preinfarctual angina. These terms have not been well defined and are
used indifferently by various doctors.
Due to acute coronary insufficiency or acute coronary syndrome (see UA / NSTEMI
coronary syndrome, ie non-overdeveled ST) we mean prolonged coronary pain (usually
for more than 30 minutes) without enzymatic or electrocardiographic signs of
myocardial infarction.
The old term of anginal state has been replaced by that of angina preinfartuale.
This pain is similar to typical anginal pain but often arises spontaneously,
without relationship to emotions or efforts and lasts for a varied period of
time, without response to rest or nitroglycerin. Angina in crescendo refers to a
type of angina pectoris which shows an increase in both frequency and severity.
The importance of the recognition of pre-infarction angina and crescendo angina
resides in the possibility of a surgery ("by-pass") or doctor (anticoagulant
therapy) to be adopted before a myocardial infarction occurs.
The electrocardiographic alterations associated with these various
manifestations of coronary artery disease are too numerous to be described in
detail.
ST-segment subtraction is observed in typical angina pectoris, while an
ST-segment elevation (SCA STEMI) is present in angina variants and myocardial
infarction.
It should be noted that patients may present a normal electrocardiogram during
angina and also in the early stages of acute myocardial infarction. Other causes
of myocardial pain include angina associated with ventricular hypertrophy.
Probably, in this case the pain is due to myocardial hypertrophy which is
excessive compared to the vascular supply. This situation is often observed in
aortic stenosis and aortic insufficiency.
The anginal pain associated with right ventricular hypertrophy is believed to be
related to a similar phenomenon, interesting right ventricle. Infrequent causes
of myocardial pain are coronary embolism, Fabry disease, carcinoid syndrome,
systolic click-systolic noise syndrome and the use of certain drugs (ergotamine,
pitressin, hydralazine, contraceptive).
Link correlati al tema:
Pulmonary embolism
Chest pain of pericardial origin