CARDIOVASCULAR DISEASES

CHEST PAIN

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 Chest Pain
Common complaint in Emergencies
Department (ED)
5% of all ED visits or 5 million visits per year
Wide range of etiologies
Cardiac, Pulmonary, Gastro Intestinal,
Musculoskeletal
Why does distinguishing these causes matter?
How do you distinguish causes of chest pain?
 Classification
Cardiac Vs Non-Cardiac causes

Cardiac:
Ischemic
- Angina pectoris
- Myocardial infarction

Non-Ischemic
- Pericarditis

Aortic
- Dissecting aneurysm
Non-Cardiac

Gastro Intestinal
- Gastro Esophagal Reflex Disease (GERD)
- Oesophagal Spasm
- Peptic Ulcer Disease (PUD)

Pulmonary (Lungs)
- Pulmonary Embolism
- Pneumothorax
- Pneumonia
- Pleurisy
- Pulmonary Hypertension

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 Angina Pectoris
Chest pain that occurs when the coronary
arteries do not deliver an adequate amount of
oxygen-rich blood to the heart
Angina Pectoris
- Myocardial ischemia with severe pain
- Choking or constricting chest pain
- Pain on exertion and relieved / remits at rest
- Pain is felt retrosternally and radiate to left arm, throat,
jaw, teeth and back
- Sqeezing, crushing, burning, aching
- Exacerbated by emotions
- Worse by large meals
- Felt severe in cold wind
- Relieved by Nitrates
(Glyceryl trinitrate)

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Categorized as stable, unstable and variant
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 Stable Angina
Substernal, high pressure/heavy feeling
Duration from 1 5 minutes
Instigated by physical exertion
Relieved with rest or nitrates
 Unstable Angina
Occurs even at rest
Unexpected
More severe and lasts longer than stable
angina, maybe as long as 30 minutes
May not disappear with rest or use of nitrates
 Variant Angina
Transient coronary vasospasm that is
associated with a fixed atherosclerotic lesion
(75 %)
Patient tends to be younger and in seemingly
good health
Occurs at rest and associated with ventricular
dysrhythmias
Nitrates and Calcium Channel Blockers (CCB)
are often effective
 Diagnosis
Resting ECG normal in
patients with Stable
Angina, ST/T wave
changes in unstable
Angina and Variant
Angina
Stress Echo - detect
ischemia, asses Left
Ventricular (LV) function
and valve disease
 Treatment
Lifestyle changes
Pharmacotherapy Aspirin, Beta Blockers,
Calcium Channel Blockers, Nitrates
Revascularization Coronary artery bypass
grafting (CABG)
 Myocardial Infarction
Interruption of blood supply which causes necrosis of
the myocardium.
Atheromatous plaque ruptures and thrombus forms
on top of the lesion causing occlusion (blocking).
MI has a 30% mortality rate.
Myocardial Infarction
Lack of blood supply to one segment of myocardium due to
occlusion (Heart Attack)

- Similar pain as Angina, but more severe

- Crushing substernal chest pain (usually >30 min)
- Radiation to arms, neck, jaw, back (Left side)
- Diaphoresis, Nausea, Vomiting, Dyspnea, Syncope
- Pain persists at rest
- Do not respond to Nitrates
- Activation of sympathetic nervous system
- Anxiety (nervousness)
- Feeling of impending death
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Diagnosis
 Diagnosis
Cardiac enzymes Gold Standard.
3 sets of CKMB-isoenzyme
Increases within 4-8 hours, peaks at 24 hrs,
and returns to normal 48 -72 hrs later
Troponin Proteins Measurement More
specific/sensitive than CKMB.
Renal failure testing
 Treatment
Admit patient to CCU, Insert IV, administer
oxygen, nitrates, morphine
Aspirin, beta-blockers, ACE Inhibitors reduce
mortality
Lovenox can slow progression of thrombosis.
Cardiac Rehabilitation - exercise + lifestyle
changes post MI
 Pericarditis Pain
Inflammation of fibrous sac (membrane)
which covers the heart
Causes:
Viral Infection (Coxsackie B, Echovirus, Hepatitis
A/B)
Myocardial Infarction
Uremia
Patients usually recover in 1-3 weeks
Pericarditis

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 Pericarditis
Clinical Features:

Pleuritis chest pain that is positional (worsened by

lying down, inspiration).
Pain is relieved by sitting up + leaning forward
Friction Rub scratching, high-pitched sound caused
by rubbing of visceral and parietal pleura
Sharp stabbing chest pain
- Pain felt retro sternally
- Radiates from left sternum to left shoulder
- Varies with the phase of respiration
 Pericarditis
Diagnosis
ECG ST elevation and PR depression, then ST
returns to normal, T-wave inverts, then
returns to normal.

Treatment
Treat underlying cause and offer NSAIDS for pain
Dissecting aortic aneurysm
- Enlargement of the aorta
- > 1.5 times of normal size
- Ballooning or bulging of walls
- Sharp and tearing pain
- Penetrate to the back
- Slow pulse with
severity of pain

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 Gastro Intestinal - GERD
Inappropriate relaxing
of Lower Esophagus
Sphincter (LES) causes
backwards flow of
stomach contents into
esophagus.

Contributing factors:
Ethanol, coffee, fatty
food intake, increased
age and Hiatal Hernia
 GERD
Clinical Features:
Burning, retrosternal pain after meals
Cough, nausea, vomiting
Hoarseness, sore throat
Reflex saliva hyper-secretion

Diagnosis:
Endoscopy w/ Biopsy - Can detect complication of
GERD or cancer
24 h pH monitoring of Lower Esophagus Gold
Standard, Highly specific/sensitive
 GERD
Treatment:
Phase I - diet changes + antacids
Phase II Add H2 blocker (Ranitidine)
Phase III Switch to proton pump inhibitor
(PPI) if symptoms dont resolve
Phase IV GI motility Agent
(bethanechol/metoclopramide)
Phase V Combination (H2 or PPI) + BTH/MET
 Peptic Ulcer Disease
A peptic ulcer is erosion in the lining of the
duodenum (stomach).

Causes:
Helico bacter pylori infection, NSAID, Zollinger-
Ellison syndrome, Smoking, Stress

Clinical Features:
Epigastric pain that is achy
Nausea, vomiting, weight loss, Upper GI bleed
 Diagnosis
Endoscopy is most accurate test
Histological evaluation of endoscope biopsy
Gold Standard for H. pylori infection
Urease Breath Test Shows active infection,
and efficacy of antibiotic therapy
Serum gastrin-specific test for ZE Syndrome
 Treatment
Lifestyle modifications (Reduce smoking,
stress, alcohol, NSAID) No food before
bedtime!
If H. pylori is present use Triple or Quadruple
therapy
Triple (PPI + 2 antibiotics)
Quadruple (PPI + Peptobismol + 2 Antibiotics)
H2 blockers help with ulcer healing
Surgical intervention need for complications of
bleeding, perforation
Pain in Lung / Pleura
- Pneumothorax (Abnormal collection of air in pleural
space i.e. between heart and lungs)
- Pleurisy or Pleuritis (Inflammation or swelling)
- Pneumonia (lung inflammation caused by bacterial or
viral infection, air sacs fill with pus and become
solid. Inflammation may affect both lungs)

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Oesophageal spasm
- Food / drink intake related
- Other variables
- Pain similar to Angina
- Relieved by nitrates

Musculo-skeletal
- Local tenderness
(Posture or movement)

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 Evaluation of Chest Pain
Focused physical exam for chest pain
General: Sick appearing, actively having chest pain
Vital Signs: Tachycardia, hypertension/hypotension
or hypoxia
Chest: Rales, wheezes or decreased breath sounds
CVS: New murmurs, reproducible chest pain
Abd: Abdominal tenderness, pulsatile mass
External: Edema, peripheral pulses
Skin: Rash on chest wall
Chest Pain That Can Kill
Acute Coronary Syndromes
Pulmonary Embolism
Aortic Dissection
Esophageal Rupture
Pneumothorax
Pneumonia
CARDIOVASCULAR DISEASES

BREATHLESSNESS

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 Breathlessness - Dyspnea
From Latin dyspnoea
Dyspnea (also termed as Shortness Of Breathe
(SOB), Air hunger)
Difficulty in breathing (or) increasing work in
breathing
It happens normally in heavy exertion
Pathological if it occurs in unexpected situations
Unpleasant, subjective sensation of abnormal
respiration.
Labored breathing - physical presentation of
respiratory distress
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 What is respiratory distress?
Vague term meaning not breathing well. The
signs include:
Using accessory muscles of respiration
Tachypnea (Abnormal rapid breathing)
Gasping (Abnormal breathing and brainstem reflex)
Panting (quick breaths)
Restlessness
Sometimes, also confusion (hypoxemia)
Somnolence (hypercarbia - Sleepiness)

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 Respiratory - Terminology
Eupnea - normal breathing
Bradypnea - decreased breathing rate
Tachypnea breathing very fast. Patient not
always aware of it.
Apnea not breathing at all (no oxygen)
Hyperpnea faster and/or deeper breathing
Hyperventilation rapid breathing with
hypocarbia (Low CO2 in blood)

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 Causes of dyspnea
Pulmonary
Cardiogenic
Psychogenic
Hypoxic
Metabolic
Hematologic
Any others?

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1. Cardiac related problems

Exertional dyspnoea (Shortness of breath -

Pulmonary circulation)

Orthopnea (sensation of breathlessness in the

recumbent position, relieved by sitting or standing)

Paroxysmal noctural dyspnoea

Night (often after 1-2 h of sleep)
Left heart failure
Lying position
Relieved in the upright position
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 Dyspnea after Eating Post Prandial Dyspnea (PPD)

Dyspnea in Pregnancy - Hormonal, mechanical

Pulmonary oedema (Accumulation of fluid in lungs)

Cheyne Stokes breathing

Periodic breathing rate increases progressively
deeper and faster

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2. Respiratory diseases

- Asthma (Inflammation of airways bronchi,

bronchioles, alveoli)

- Chronic Obstructive Pulmonary Disease (COPD)

- Pneumonia (Inflammation due to viral infection)

- Bronchitis (Inflammation of bronchus)

- Laryngeal / Tracheal obstruction

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3. Others

- Anaphylaxis (shock)

- Severe anaemia

- Toxic gas inhalation

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ANATOMY OF RESPIRATORY SYSTEM

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 Asthma
Reversible broncho-constriction
Air blocked between the large airways to the
alveoli.
Alveoli may collapse.
Treatment: Open the airways, prevent stacking
(time enough for exhalation). Keep O2 high
enough to keep patients brain alive.
Treatment - steroids, permissive hypercarbia.

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 Pulmonary edema
Primary problem: Heart stretches so far it cant
contract well.
Cardiac oxygen demand exceeds availability.
Air cant cross the air-blood interface.
Fluid seeps from the blood into the alveoli.
Caused by cardiac and vascular dearrangements.
Vicious cycle (sequence of reciprocal cause and
effect).

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 Pulmonary edema
Symptoms:
Sudden onset; respiratory distress
Rales & ronchi (abnormal rattling sound).
Foamy sputum and sometimes blood tinged.
Blood pressure high (vasoconstriction) usually
240/120.
If onset between 4 pm and 8 pm, likely to be
associated with acute MI.
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 Pulmonary edema
Treatment:
increase airway pressure, to force fluids back into
the vascular system
Bag-Valve-Mask (BVM) with patient effort
Continuous Positive Airway Pressure (CPAP)
Intubation
increase the fraction of inspired oxygen (FiO2)
dilate blood vessels and reduce systemic blood
pressure (which reduces the work of the heart
and reduces oxygen demand)
Get excess fluid off via kidneys (if working), via
bleeding (blood letting)
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 Diabetic KetoAcidosis - DKA
Tachypnea often without Air hunger
Metabolic derangement: blood is too acid.
Acetone breathe
Respiratory system tries to compensate

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 Pneumo / hemo thorax.
Stuff gets between the inside of the chest wall
and the lung. Air cant get-in well, and blood
cant circulate well enough.
Treatment: mechanically remove the stuff that
keeps the lung collapsed.
Eg: Needle with flutter valve, or chest tube.

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 Pneumonia
Infection in the lower airway may lead to fluid in
alveoli
Often only one part of a lung is affected
Upper, middle and lower airways clogged by mucus
Generally SICK.
Fever increases metabolic demand for O2.
Treatment:
Antibiotics if bacterial
Thin the mucus
Mechanical ventilation if needed.

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 Pulmonary Embolism
A blood clot in the pulmonary circulation (often from
the systemic venous circulation) blocks.
Blood cant circulate well, so there is lack of oxygen
in the circulating blood.
Diagnosis: hypoxemia, tachycardia, tachypnea,
sometimes chest pain.
Treatment: anticoagulation and O2 supplementation.
CO2 is usually normal.

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 Emphysema
Not enough functional lung tissue. That is, a
paucity of the blood/air interface.
Optimize all functioning tissue.
Treatment: Lungs replacement / Artificial
Lungs surgery

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 CO poisoning
Competitive inhibition of O2 binding at
hemoglobin site.
Treatment: Overwhelm the CO with 100% O2.
If not good enough, use hyperbaric O2.

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 Cyanide poisoning
Mechanism: Inhibition of O2 utilization at the
cellular level. There can be plenty of O2 in the
air, and in the blood, but the cells cant use it.
Treatment: Inactivate the cyanide using BAL
British Anti-Lewisite.
Time sensing treatment

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Thank YOU

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