Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis (29 page)

   See Table
2-1
.

Chapter
3

Cardiovascular Disorders

Craig S. Smith

Chest Pain

Chest Pain: Acute Coronary Syndromes

Chest Pain: Nonatherosclerotic Ischemia

Chest Pain: Inflammatory

Vasculitis

Antiphospholipid Antibody Syndrome

Henoch-Schönlein Purpura

Kawasaki Syndrome (Mucocutaneous Lymph Node Syndrome)

Takayasu Syndrome (Arteritis)

Thromboangiitis Obliterans (Buerger Disease)

Infectious (Secondary) Vasculitis

Thrombophlebitis, Septic

Pericarditis (Acute) and Pericardial Effusion

Chest Pain: Hyperadrenergic States

Chest Pain: Noncardiac Etiology

Acute Aortic Syndromes

Chest Pain: Musculoskeletal

Dyspnea

Congestive Heart Failure

Systolic Dysfunction/Dilated Cardiomyopathy (DCM)

Myocarditis

Heart Failure with Preserved Ejection Fraction (HF
p
EF)

Pericardial Constriction

Syncope and Sudden Cardiac Arrest

Syncope

Sudden Cardiac Arrest

Hypertension

Hyperlipidemia

Disorders of Lipid Metabolism

Acid Lipase Deficiencies

Metabolic Syndrome

Atherogenic Dyslipidemia

Hyperalphalipoproteinemia (HDL-C Excess)

Severe Hypertriglyceridemia (Type I) (Familial Hyperchylomicronemia Syndrome)

Familial Hypercholesterolemia (Type II)

Polygenic Hypercholesterolemia (Type IIA)

Familial Combined Hyperlipidemia (Types IB, IV, V)

Familial Dysbetalipoproteinemia (Type III)

Abetalipoproteinemia (Bassen- Kornzweig Syndrome)

Hypobetalipoproteinemia

Tangier Disease

Lecithin–Cholesterol Acyltransferase Deficiency (Familial)

Atherosclerosis

This Chapter focuses on the common presenting symptoms and conditions of cardiovascular disorders and the differential diagnoses to be considered in the evaluation of the patient. Chest pain, dyspnea, syncope/sudden cardiac death, hypertension, and dyslipidemia are discussed and further subdivided by clinical presentation and diagnostic approach.

CHEST PAIN

CHEST PAIN: ACUTE CORONARY SYNDROMES

   Definition

   Chest pain accounts for over 6 million annual emergency department visits and 3 million hospital admissions in the United States. The differential diagnosis for chest pain is broad and ranges from benign musculoskeletal conditions to life-threatening emergencies.

   The prevalence of chest pain etiology varies greatly by location of the patient interaction. Acute coronary syndromes account for <2% of outpatient chest pain visits as opposed to 15% of emergency room visits. Of central importance in the evaluation of the patient with chest pain is a thorough history and physical supported by ancillary testing to determine if emergent treatment is required.

   Initial clinical assessment is focused on immediate threats to life: acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, and mediastinitis (esophageal rupture).

   Evaluation of the patient with chest pain should differentiate non-cardiac from cardiac etiologies. Acute coronary syndrome (ACS) is a unifying term representing the potentially life-threatening syndrome of myocardial ischemia that results from a disparity between coronary blood flow and myocardial oxygen demand most often due to atherosclerosis, vasoconstriction, or thrombus with superimposed myonecrosis. ACS syndromes present as unstable angina (UA), or myocardial infarction either with ST-segment elevation on ECG (STEMI) or without (NSTEMI).

   NSTEMI and unstable angina comprise two thirds of ACS.

   Immediate recognition of ACS in patients presenting with chest pain is important as the diagnosis triggers both triage and treatment decisions.