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INTRODUCTION

There is little correlation between the severity of chest pain and the seriousness of its cause. The range of disorders that cause chest discomfort is shown in Table 33-1.

TABLE 33-1Diagnoses of Pts Admitted to Hospital with Acute Chest Pain Ruled Not Myocardial Infarction

POTENTIALLY SERIOUS CAUSES

The differential diagnosis of chest pain is shown in Figs. 33-1 and 33-2. It is useful to characterize the chest pain as (1) new, acute, and ongoing; (2) recurrent, episodic; and (3) persistent, e.g., for hours or days at a time.

FIGURE 33-1

Differential diagnosis of recurrent chest pain. *If myocardial ischemia suspected, also consider aortic valve disease (Chap. 116) and hypertrophic obstructive cardiomyopathy (Chap. 117) if systolic murmur present. TNG, trinitroglycerin.

FIGURE 33-2

Differential diagnosis of serious conditions that cause acute chest pain. CK, creatine phosphokinase.

Myocardial Ischemia: Angina Pectoris

Substernal pressure, squeezing, constriction, with radiation often to left arm; usually on exertion, especially after meals or with emotional arousal. Characteristically relieved by rest and nitroglycerin.

Acute Myocardial Infarction or Unstable Angina

Similar to angina but more severe, of longer duration (≥30 min), and not immediately relieved by rest or nitroglycerin (Chaps. 121 and 122). S3 and/or S4 may be present.

Pulmonary Embolism

May be substernal or lateral, pleuritic in nature, and associated with hemoptysis, tachycardia, and hypoxemia (Chap. 135).

Thoracic Aortic Aneurysm

May impinge on neighboring structures and cause deep, persistent chest pain, dysphagia, hoarseness, or cough (Chap. 127).

Aortic Dissection

Very severe, in center of chest, a sharp “ripping” quality, radiates to back, not affected by changes in position (Chap. 127). May be associated with weak or absent peripheral pulses.

Mediastinal Emphysema

Sharp, intense, localized to substernal region; often associated with audible crepitus.

Acute Pericarditis

Usually steady, crushing, substernal; often has pleuritic ...

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