Nirali DesaiBPA 1: Have a Disease

Chest Pain

Chest pain has several etiologies, which include cardiac, noncardiac, or psychogenic causes. (Tierney, 2012). The most common cause of chest pain is acute cardiac ischemia, which includes angina and myocardial infarction (MI). Other less common causes include, aortic dissection, pulmonary embolism, spontaneous pneumothorax, and pneumonia (Tierney, 2012). Understanding the character of pain, other symptoms, and medical conditions will differentiate angina pain from noncardiac pain.

In the United States, there are approximately 10,000 cases of acute aortic dissection per year (Braverman, 2011). Aortic dissections are either severe type A involving the ascending aorta or the less risky type B. Aortic dissection can mimic other conditions, like coronary ischemia, pleurisy, heart failure, stroke, and acute abdominal illness; however, since aortic dissections can be fatal, prompt diagnosis and treatment are crucial (Braverman, 2011). More than 90% of patients present with acute chest and/or back pain with severe, sharp or tearing, ripping, and stabbing qualities (Braverman, 2011). This pain differs from MI or angina, because it is severe at onset. Patients may also feel anxious and have an impending sense of doom (Braverman, 2011).

Physical exam findings can include an unequal or absent pulse, syncope, and neurologic manifestations, such as persistent or transient ischemic stroke, spinal cord ischemia, ischemic neuropathy, and hypoxic encephalopathy (Braverman, 2011). Many patients have prior hypertension or heavy lifting, and cocaine use. Neurologic conditions are important, because they may lead to a delay in diagnosis aortic dissection. Additional physical exam findings include, left-sided pleural effusion, usually related to inflammation and acute hemothorax, which may occur from rupture or leaking descending aortic dissection (Braverman, 2011).

Chest radiography will provide the first clues of an aortic dissection. The most frequent finding is a widened aortic shadow or an abnormal aortic contour. Contrast enhanced computed tomography (CT) is also commonly used for diagnosis and may show hemopericardium, aortic rupture, and branch vessel involvement. Electrocardiography is typically normal, unless acute MI precedes the aortic dissection (Braverman, 2011). Biomarkers have also gauged significant interest in aortic dissection diagnoses. D-dimer levels greater than 1,600 ng/mL within 6 hours has a high positive likelihood for aortic dissection and could be useful in diagnosing patients with a high probability of disease (Braverman, 2011).

Administration of a beta-blocker, such as intravenous esmolol or labetolol, is necessary to reduce stress on the aorta. Emergency surgery and endovascular stenting may also be required in acute situations. Type A dissections require urgent surgical replacement of the aorta, while type B After initial treatment; lifelong management must be sustained for

successful outcomes. Long-term management includes, blood pressure control via medications and monitoring, lifestyle modification, consistent imaging of the aorta via CT or MRI, patient education, and when appropriate, screening of family members for aortic disease (Braverman, 2011).

References

Braverman, A.C. 2011. Aortic dissection: prompt diagnosis and emergency are critical. Cleveland clinic journal of medicine. 78 (10).

Henderson, M., Tierney, Jr., L., & Smetana, G. (2012). Chest pain. The Patient History: Evidence-Based Approach. New York: Lange Medical Books/McGraw-Hill Medical Pub. Division.