Aortic dissection

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Dissection of the aorta causes pain thai is usually of sudden onset. It is very severe, often described as tearing in nature and is frequently initially felt in the back between the shoulder blades (Table 3.1 1).

TABLE 3.8 Differential diagnosis: angina vs oesophageal pain

Angina

Oesophageal pain

Usually precipitated by exertion

Rapidly relieved by rest Retrosternal and radiates to arm and jaw

Seldom wakes patient from sleep No relation to heartburn (but patients often have 'wind') Rapidly relieved by nitrates Typical duration 2-10 minutes

Can be worsened by exertion, but often present at other times Not rapidly relieved by rest Retrosternal or epigastric, sometimes radiates to arm or back Often wakes patient from sleep Sometimes related to heartburn

Often relieved by nitrates Variable duration

TABLE 3.9 Differential diagnosis: angina vs myocardial infarction

Angina

Myocardial infarction

Site: retrosternal, radiates to arm, epigastrium, neck Precipitated by exercise or emotion Relieved by rest, nitrates Mild/moderate severity Anxiety absent or mild No increased sympathetic activation No nausea or vomiting

As for angina

Often no obvious precipitant Mot relieved by rest, nitrates Usually severe (may be 'silent') Variable anxiety or angor amini Increased sympathetic activity Nausea and vomiting are common

TABLE 3.10 Characteristics of pericardiac pa In

Site

Retrosternal, may radiate to left shoulder or back

Prodrome

May be preceded by a viraf illness

Onset

No obvious initial precipitating factor; tends to

fluctuate in intensity

Nature

May be stabbing or 'raw' - like sandpaper'. Often

described as sharp, rarely as tight or heavy

Made worse by

Changes in posture, respiration

Helped by

Analgesics, especially NSAIDs

Accompanied by

Pericardial rub

TABLE 3.11 Characteristics of pain caused by dissection of aortic

aneurysm

Site

Gten first felt between shoulder blades, ancf/or

retrosternal^

Onset

Usually sudden

Nature

Very severe pain, often described as 'tearing' In nature

Relieved by

Tends to persist. Patients often restless with pain

Accompanied by

Hypertension, asymmetric pulses, unexpected

bradycardia, early diastolic murmur, syncope, focal

neurological symptoms and signs

TABLE 3.12 New York Heart Association classification of heart failure symptom severity

Class I

No limitations. Ordinary physical activity does not cause undue fatigue, dyspnoea or palpitation (asymptomatic left ventricular dysfunction)

Class II

Slight limitation of physical activity. Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnoea or angina pectoris (symptomatica^ 'mild' heart failure)

Ciass III

Marked limitation of physical activity, Less than ordinary physical activity will lead to symptoms (symptomatically 'moderate' heart failure)

Class IV

Symptoms of congestive cardiac failure are present even at rest. With any physical activity increased discomfort is experienced (symptomatically 'severe' heart failure)

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