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Nirali Desai

BPA 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).
Physicalexamfindingscanincludeanunequalorabsentpulse,syncope,andneurologic
manifestations,suchaspersistentortransientischemicstroke,spinalcordischemia,
ischemicneuropathy,andhypoxicencephalopathy(Braverman,2011).Manypatients
havepriorhypertensionorheavylifting,andcocaineuse.Neurologicconditionsare
important,becausetheymayleadtoadelayindiagnosisaorticdissection.Additional
physicalexamfindingsinclude,leftsidedpleuraleffusion,usuallyrelatedto
inflammationandacutehemothorax,whichmayoccurfromruptureorleaking
descendingaorticdissection(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.