sgd 1: acute myocardial infarction. pathology chest pain an unpleasant sensation in the anterior...
TRANSCRIPT
SGD 1: Acute Myocardial Infarction
PATHOLOGY
Chest Pain
• An unpleasant sensation in the anterior wall of the thorax– actual or potential tissue damage– mediated by specific nerve fiber to the brain -
conscious appreciation may be modified by various factors.
Organ System Character of pain Location of pain Examples
CardiovascularPressureTightnessHeaviness
Retrosternal, radiates to the
neck, jaw, shoulders or
arms
• Coronary artery disease• Ischemic heart disease• Aortic stenosis• Pericarditis• Hypertrophic cardiomyopathy
Pulmonary SharpSubsternal
Unilateral or localized
• Pneumonia or pleuritis• Pulmonary embolism• Pneumothorax• Tumor
Gastrointestinal
BurningPresents
with abdominal
pain
RetrosternalSubsternalEpigastric
• Gastroesophageal reflux disease• Esophageal spasm• Peptic ulcer disease• Biliary diseases• Pancreatitis
Musculoskeletal StabbingDull ache
SuperficialLocalized
• Cervical disk disease• Arthritis of the shoulder and spine• Costochondritis• Intercostal muscle cramps
Condition Location Quality Duration Aggravating or Relieving
Factors
Associated Symptoms or Signs
Angina Retrosternal region; radiates or occasionally isolated to neck, jaw, epigastrium, shoulder or arms—left common
Pressure, burning, squeezing, heaviness, indigestion
<2-10 min Precipitated by exercise, cold weather, or emotional stress, relieved by rest or nitroglycerin; atypical (Prinzmetal’s) angina may be unrelated to activity, often early morning
S4, or murmur of papillary muscle dysfunction during pain
Rest or unstable angina Same as angina
Same as angina but may be more severe
Usually <20 min
Same as angina, with decreasing tolerance for exertion or at rest
Similar to stable angina, but may be pronounced. Transient cardiac failure can occur
Braunwald and Goldman, Primary Cardiology 2nd ed
Condition Location Quality Duration Aggravating or Relieving Factors
Associated Symptoms or Signs
Myocardial infarction
Substernal and may radiate like angina
Heaviness, pressure, burning
Sudden onset, 30 min or longer
Unrelieved by rest or nitroglycerin
Shortness of breath, sweating, weakness, nausea, vomiting
Pericarditis Usually begins over sternum or toward cardiac apex and may radiate to neck or left shoulder; often more localized than the pain of myocardial ischemia
Sharp, stabbing, knifelike
Lasts many hours to days; may wax and wane
Aggravated by deep breathing, rotating chest, or supine position; relieved by sitting up and leaning forward
Pericardial friction rub
Aortic dissection
Anterior of chest; may radiate to back
Excruciating, tearing, knifelike
Sudden onset, unrelenting
Usually occurs in setting of hypertension or predisposition such as Marfan’s syndrome
Murmur of aortic insufficiency, pulse or blood pressure asymmetry; neurologic deficit
Braunwald and Goldman, Primary Cardiology 2nd ed
Chest Pain
(dark red = most typical area, light red = other possible areas)
Atherogenesis
• Developmental process of atheromatous plaques.
Pathogenesis of Atherosclerosis
• Fatty Streak
• Leukocyte recruitment
• Foam Cell formation
• Microvessels
• Plaque evolution
Atherothrombosis
• Arterial Remodelling
• Rupture of Fibrous cap
• Arterial Occlusion
• More fibrous lesion
Risk Factors• Cigarette Smoking • HPN (BP> 140/90 mmHg or on
antihypertensive medication)• Low HDL, Low LDL• DM• Family Hx of premature CHD
– CHD in male first degree relatives<55y/o
– CHD in female first degree relatives<65y/o
• Lifestyle risk factors– BMI = > 30 kg/m²– Physical inactivity– Atherogenic diet
• Age (male>55y/o, female >65y/o)• Sex (Male>Female)• Stress
• Age (55 y/o)• Male• Occupational stress• 40 pack years • Heavy alcoholic beverage
drinker• HPN (2003)• Usual BP 130-80• Highest BP 170/100• Nifedipine 30 mg – irregular
intake• Family Hx of DM, HPN,
Premature CAD
Clinical Features of Angina
• Described as heaviness, pressure, squeezing, smothering, or choking, and only rarely as frank pain.
• Levine’s sign – localization of pain by the pain: placing his hand (clenched fist) over the sternum to indicate sqeezing, central, substernal discomfort.
• Crescendo-decrescendo (2-5 min)• Radiates to either shoulder and to both arms (ulnar
surface of the forearm and hand).• Also arise in or radiate to the back, interscapular region,
root of the neck, jaw teeth and epigastrium.
Types of Angina Pectoris
New York Heart Association Functional Classification
I. Px have cardiac disease but without the resulting limitations of physical activity does not cause undue fatigue, palpitation, dyspnea or anginal pain
II. Px have cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
New York Heart Association Functional Classification
III. Px have caridac disease resulting to marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.
IV. Px have cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.
Canadian Cardiovascular Society Classification of Angina
I. No angina with ordinary activity. Angina with strenuous, rapid, or prolonged exertion
II. Slight limitation of ordinary activity; angina when walking up stairs briskly, or walking on a cold or windy day
III. Marked limitation; angina when walking at normal pace up flight of stairs, or walking 1-2 blocks distance
IV. Angina on minimal exertion or at rest
WHO Criteria for AMI
Classic WHO Criteria: two (probable) or three (definite) of the following criteria are satisfied:
• Clinical history of ischemic type chest pain lasting for more than 20 minutes
• Changes in serial ECG tracings • Rise and fall of serum cardiac biomarkers such as CK-MB fraction
and troponin
Revised (2000) Cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression or coronary intervention are diagnostic of MI.