1. Ischemic heart disease and Cardiac Mechanics
Cocaine-associated Chest Pain
Ischemic heart disease
Cocaine-associated Chest Pain
A 27-year-old male is brought to the hospital ED by paramedics with chest pain. The patient is a member of a rock-and-roll band that practices during the day and plays in local clubs at night. On scene, he denied any medical problems, including cardiovascular disease. He also denied the use of prescribed medications but admitted to daily use of cocaine, including intranasal cocaine approximately 45 min ago. He complained of pain radiating to both upper extremities and nausea. The physical examination was notable for unstable vital signs, hypoxemia, an anxious, diaphoretic patient. The EKG revealed He was given SL nitroglycerin with relief of symptoms. Prior to transport to the ED, he was given an aspirin to chew, supplemental oxygen, and iv fluids were started.
• Want constitutes a complete cardiac examination in this patient? What abnormalities, if any, do you anticipate and why?
• Discuss the other cardiovascular disorders associated with cocaine abuse
• Why are beta blockers contraindicated in this patient?
• Discuss the physiologic basis for cocaine-associated cardiovascular toxicity
• Discuss the sympathomimetic effects of cocaine
• Discuss the thrombogenic effects of cocaine and describe in detail thrombus formation
• Discuss acute cocaine intoxication
• Discuss the mechanisms underlying cocaine-induced myocardial ischemia
• Discuss the pathogenesis of cocaine-associated cardiomyopathy
• Discuss the common EKG abnormalities associated with cocaine toxicity
• What is the differential diagnosis in this patient?
• What serum markers would you like to order?
• Discuss reperfusion strategies in patients with myocardial ischemia/infarction
A 46-year-old male is brought to the Emergency Department after the sudden onset of retrosternal chest pain that began 1 h ago. He describes the pain as sharp, constant, and unaffected by movement. The pain is not relieved by three doses of sublingual nitroglycerin administered by the paramedics while en route to the hospital. This is the first time he has experienced these symptoms. He takes enalapril for hypertension. There is no history of cardiac disease in his family. He does not smoke, use alcohol, or illicit drugs. He is an accountant, but is physically active. On physical examination, he is a tall man with long arms and legs who appears uncomfortable and diaphoretic. He is afebrile, with a heart rate of 118 beats per min, a blood pressure of 154/98 mmHg in the right arm and 186/92 mmHg in the left arm. He has pectus excavatum. There is a soft, early diastolic murmur at the right sternal border. His abdominal examination shows no abnormalities, and the neurologic examination is non-focal. His chest X-ray shows a widened mediastinum. The impression is aortic dissection as the cause of pain in a man with Marfan syndrome.
• Explain how an intramural aortic hematoma develops from bleeding from the vasa vasorum or a tear in the intima of the aorta
• Distinguish between type A (involving the ascending aorta) and type B aortic dissections
• Describe the role of degeneration of the collagen and elastin in the media leading to aortic dissection and the pathogenesis of aortic dissection
• Describe the clinical manifestations of aortic dissection
• Why are aortic dissections associated with an early diastolic murmur of aortic insufficiency?
• Describe the diagnosis of suspected aortic dissection
• Describe treatment by lowering blood pressure and surgical repair
• Why is surgical repair more urgent for type A dissection than for type B?
• Describe prognosis of type A dissection
• What features distinguish aortic dissection from myocardial infarction?
A 27-year-old male with no history of heart or lung disease presents to the ED with pleuritic pain in the left side of the chest of about 3 hours duration. The pain radiates to the left trapezius ridge, is made worse by coughing, and is relieved by leaning forward. On PE, his temperature is 37.8o C and he appears anxious. His heart rate is 106 beats per minute and regular and his blood pressure is 128/82 mmHg without evidence of a paradoxical pulse. A 3-component friction rub is heard along the left sternal border. An ECG shows ST-segment elevation in multiple leads, which are consistent with acute pericarditis.
• Describe the innervation of the pericardium and the fact that congenital absence or surgical resection does not appear to have major adverse effects
Nerve supply of the pericardium: Fibrous pericardium and the parietal layer of serous pericardium are supplied by phrenic nerves. The visceral layer of serous pericardium has different innervations than the parietal layer. It is innervated by branches of sympathetic trunks and vagus nerves.
• Review causes of isolated acute pericarditis, of which about 85% are considered to be caused by viruses (echovirus, coxsackievirus) and other infections agents
• Describe the major clinical manifestations of acute pericarditis, and the presence of pain referred to the scapular ridge, presumed secondary to irritation of the phrenic nerves
• Describe a pericardial friction rub and differentiate chest pain of acute pericarditis from that of pulmonary embolism and myocardial ischemia or infarction
• Describe tests used to diagnose acute pericarditis
• Identify those patients who should be hospitalized
• Review therapy with ibuprofen in conjunction with colchicine and proton pump inhibitors to protect the gastric mucosa
• Summarize prognosis of viral and idiopathic pericarditis
• Describe paradoxical pulse
Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration.
A 61-year-old male with a history of hypertension and cigarette smoking presents to his primary care physician with a 2-day history of constant and gnawing hypogastric pain. The pain has been growing steadily worse in intensity and he states that the pain radiates to his lower back and groin. There is a palpable pulsatile mass to the left of midline below the umbilicus. An emergency transport vehicle is called to take him to the hospital for definitive treatment, but on the way he becomes hypotensive and unresponsive.
• Describe the anatomy of the ascending aorta, aortic arch, descending aorta, and abdominal aorta
• Describe the three layers of the aorta
• Define an aneurysm, and distinguish among a fusiform aneurysm, saccular aneurysm, and a false or pseudoaneurysm
• Review the epidemiology of abdominal aortic aneurysms and thoracic aneurysms
• Describe the association of ascending thoracic aneurysms with Marfan and Ehlers-Danlos syndrome
• Discuss the declining rates of deaths from abdominal aortic aneurysms in association with the declining rates of tobacco use
• Discuss the pathobiology of abdominal aortic aneurysms and the role of degradation of elastin and collagen by matrix metalloproteinases and macrophages and T lymphocytes
• Discuss the role of cystic medial degeneration in aneurysms of the ascending thoracic aorta
• Describe the range of clinical manifestations of aortic aneurysms
• Describe the diagnosis of abdominal aortic aneurysms and identify the classic triad of findings
• Discuss the role of ultrasound and computed tomography in diagnosis.
• Describe surgical methods of repair and surveillance of abdominal aneurysms
• Discuss prevention by surveillance
• Discuss prognosis