Prinzmetal's angina: Difference between revisions

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'''For main page on Acute coronary syndrome, [[Acute coronary syndrome|click here]]'''<br>
'''For main page on Acute coronary syndrome, [[Acute coronary syndrome|click here]]'''<br>
{{SI}}
{{SI}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}},{{ADS}} {{RAK}}
 
{{SK}} Variant angina; angina inversa; vasospastic angina
{{SK}} Variant angina; angina inversa; vasospastic angina


==Overview==
==Overview==


Prinzmetal's angina is a syndrome typically consisting of [[Angina pectoris|angina]] (cardiac chest pain) at rest that occurs in periodic cycles. Prinzmetal's angina is caused by [[vasospasm]], a narrowing of the [[coronary arteries]] caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to [[atherosclerosis]] (buildup of fatty plaque and hardening of the arteries).
Vasospastic angina was previously referred to as Prinzmetal or variant angina. Vasospastic angina is a syndrome typically consisting of [[Angina pectoris|angina]] (cardiac chest pain) at rest that occurs in periodic cycles. Vasospastic angina is caused by [[vasospasm]], a narrowing of the [[coronary arteries]] caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to [[atherosclerosis]] (buildup of fatty plaque and hardening of the arteries).


==Historical Perspective==
==Historical Perspective==
Line 53: Line 52:
*Genetic factors and insulin resistance
*Genetic factors and insulin resistance
**There is some evidence that genetic factors and insulin resistance are associated with vasospastic angina
**There is some evidence that genetic factors and insulin resistance are associated with vasospastic angina
*Patients with vasospastic angina are often younger and exhibit fewer classic cardiovascular risk factors (except smoking).
*Vasospastic angina may be associated with other vasospastic disorders, such as Raynaud's phenomenon and migraine headache or its treatment [54-56].
*A history of drug abuse such as cocaine may be present.
*Hyperventilation can precipitate attacks of vasospastic angina [57].


==Differential diagnosis==
==Differential diagnosis==
===Differentiating the Life Threatening and Ischemic Causes of Chest Pain from other Disorders===
Vasopastic angina must be differentiated from other diseases that cause chest pain, view [[chest pain differential diagnosis]] for more.
 
'''The following table outlines the major differential diagnoses of chest pain:'''<ref name="pmid8704488">{{cite journal |vauthors=Svavarsdóttir AE, Jónasson MR, Gudmundsson GH, Fjeldsted K |title=Chest pain in family practice. Diagnosis and long-term outcome in a community setting |journal=Can Fam Physician |volume=42 |issue= |pages=1122–8 |date=June 1996 |pmid=8704488 |pmc=2146490 |doi= |url=}}</ref><ref name="pmid8163958">{{cite journal |vauthors=Klinkman MS, Stevens D, Gorenflo DW |title=Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network |journal=J Fam Pract |volume=38 |issue=4 |pages=345–52 |date=April 1994 |pmid=8163958 |doi= |url=}}</ref><ref name="pmid19883149">{{cite journal |vauthors=Bösner S, Becker A, Haasenritter J, Abu Hani M, Keller H, Sönnichsen AC, Karatolios K, Schaefer JR, Seitz G, Baum E, Donner-Banzhoff N |title=Chest pain in primary care: epidemiology and pre-work-up probabilities |journal=Eur J Gen Pract |volume=15 |issue=3 |pages=141–6 |date= 2009 |pmid=19883149 |doi=10.3109/13814780903329528 |url=}}</ref><ref name="pmid21391528">{{cite journal |vauthors=Ebell MH |title=Evaluation of chest pain in primary care patients |journal=Am Fam Physician |volume=83 |issue=5 |pages=603–5 |date=March 2011 |pmid=21391528 |doi= |url=}}</ref><ref name="pmid11041906">{{cite journal |vauthors=von Kodolitsch Y, Schwartz AG, Nienaber CA |title=Clinical prediction of acute aortic dissection |journal=Arch. Intern. Med. |volume=160 |issue=19 |pages=2977–82 |date=October 2000 |pmid=11041906 |doi= |url=}}</ref><ref name="pmid2730190">{{cite journal |vauthors=Pate JW, Walker WA, Cole FH, Owen EW, Johnson WH |title=Spontaneous rupture of the esophagus: a 30-year experience |journal=Ann. Thorac. Surg. |volume=47 |issue=5 |pages=689–92 |date=May 1989 |pmid=2730190 |doi= |url=}}</ref><ref name="pmid7954018">{{cite journal |vauthors=Fleet RP, Dupuis G, Marchand A, Burelle D, Beitman BD |title=Panic disorder, chest pain and coronary artery disease: literature review |journal=Can J Cardiol |volume=10 |issue=8 |pages=827–34 |date=October 1994 |pmid=7954018 |doi= |url=}}</ref><ref name="pmid3270082">{{cite journal |vauthors=Bass C, Chambers JB, Kiff P, Cooper D, Gardner WN |title=Panic anxiety and hyperventilation in patients with chest pain: a controlled study |journal=Q. J. Med. |volume=69 |issue=260 |pages=949–59 |date=December 1988 |pmid=3270082 |doi= |url=}}</ref><ref name="pmid64694">{{cite journal |vauthors=Evans DW, Lum LC |title=Hyperventilation: An important cause of pseudoangina |journal=Lancet |volume=1 |issue=8004 |pages=155–7 |date=January 1977 |pmid=64694 |doi= |url=}}</ref><ref name="pmid9246027">{{cite journal |vauthors=Ros E, Armengol X, Grande L, Toledo-Pimentel V, Lacima G, Sanz G |title=Chest pain at rest in patients with coronary artery disease. Myocardial ischemia, esophageal dysfunction, or panic disorder? |journal=Dig. Dis. Sci. |volume=42 |issue=7 |pages=1344–53 |date=July 1997 |pmid=9246027 |doi= |url=}}</ref><ref name="pmid9594945">{{cite journal |vauthors=Ben Freedman S, Tennant CC |title=Panic disorder and coronary artery spasm |journal=Med. J. Aust. |volume=168 |issue=8 |pages=376–7 |date=April 1998 |pmid=9594945 |doi= |url=}}</ref><ref name="pmid17909127">{{cite journal |vauthors=Smoller JW, Pollack MH, Wassertheil-Smoller S, Jackson RD, Oberman A, Wong ND, Sheps D |title=Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women's Health Initiative Observational Study |journal=Arch. Gen. Psychiatry |volume=64 |issue=10 |pages=1153–60 |date=October 2007 |pmid=17909127 |doi=10.1001/archpsyc.64.10.1153 |url=}}</ref><ref name="pmid12426266">{{cite journal |vauthors=Mehta NJ, Khan IA |title=Cardiac Munchausen syndrome |journal=Chest |volume=122 |issue=5 |pages=1649–53 |date=November 2002 |pmid=12426266 |doi= |url=}}</ref><ref name="pmid16304077">{{cite journal |vauthors=Swap CJ, Nagurney JT |title=Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes |journal=JAMA |volume=294 |issue=20 |pages=2623–9 |date=November 2005 |pmid=16304077 |doi=10.1001/jama.294.20.2623 |url=}}</ref><ref name="pmid17208083">{{cite journal |vauthors=Marcus GM, Cohen J, Varosy PD, Vessey J, Rose E, Massie BM, Chatterjee K, Waters D |title=The utility of gestures in patients with chest discomfort |journal=Am. J. Med. |volume=120 |issue=1 |pages=83–9 |date=January 2007 |pmid=17208083 |doi=10.1016/j.amjmed.2006.05.045 |url=}}</ref><ref name="pmid17850647">{{cite journal |vauthors=Verdon F, Burnand B, Herzig L, Junod M, Pécoud A, Favrat B |title=Chest wall syndrome among primary care patients: a cohort study |journal=BMC Fam Pract |volume=8 |issue= |pages=51 |date=September 2007 |pmid=17850647 |pmc=2072948 |doi=10.1186/1471-2296-8-51 |url=}}</ref><ref name="pmid4086742">{{cite journal |vauthors=Davies HA, Jones DB, Rhodes J, Newcombe RG |title=Angina-like esophageal pain: differentiation from cardiac pain by history |journal=J. Clin. Gastroenterol. |volume=7 |issue=6 |pages=477–81 |date=December 1985 |pmid=4086742 |doi= |url=}}</ref><ref name="pmid9786377">{{cite journal |vauthors=Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL |title=The rational clinical examination. Is this patient having a myocardial infarction? |journal=JAMA |volume=280 |issue=14 |pages=1256–63 |date=October 1998 |pmid=9786377 |doi= |url=}}</ref><ref name="pmid2313224">{{cite journal |vauthors=Berger JP, Buclin T, Haller E, Van Melle G, Yersin B |title=Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain |journal=J. Intern. Med. |volume=227 |issue=3 |pages=165–72 |date=March 1990 |pmid=2313224 |doi= |url=}}</ref><ref name="pmid11676323">{{cite journal |vauthors=Yelland MJ |title=Back, chest and abdominal pain. How good are spinal signs at identifying musculoskeletal causes of back, chest or abdominal pain? |journal=Aust Fam Physician |volume=30 |issue=9 |pages=908–12 |date=September 2001 |pmid=11676323 |doi= |url=}}</ref><ref name="pmid24791662">{{cite journal |vauthors=Chan S, Maurice AP, Davies SR, Walters DL |title=The use of gastrointestinal cocktail for differentiating gastro-oesophageal reflux disease and acute coronary syndrome in the emergency setting: a systematic review |journal=Heart Lung Circ |volume=23 |issue=10 |pages=913–23 |date=October 2014 |pmid=24791662 |doi=10.1016/j.hlc.2014.03.030 |url=}}</ref><ref name="pmid14678917">{{cite journal |vauthors=Henrikson CA, Howell EE, Bush DE, Miles JS, Meininger GR, Friedlander T, Bushnell AC, Chandra-Strobos N |title=Chest pain relief by nitroglycerin does not predict active coronary artery disease |journal=Ann. Intern. Med. |volume=139 |issue=12 |pages=979–86 |date=December 2003 |pmid=14678917 |doi= |url=}}</ref><ref name="pmid6638047">{{cite journal |vauthors=Pryor DB, Harrell FE, Lee KL, Califf RM, Rosati RA |title=Estimating the likelihood of significant coronary artery disease |journal=Am. J. Med. |volume=75 |issue=5 |pages=771–80 |date=November 1983 |pmid=6638047 |doi= |url=}}</ref><ref name="pmid11739341">{{cite journal |vauthors=Buntinx F, Knockaert D, Bruyninckx R, de Blaey N, Aerts M, Knottnerus JA, Delooz H |title=Chest pain in general practice or in the hospital emergency department: is it the same? |journal=Fam Pract |volume=18 |issue=6 |pages=586–9 |date=December 2001 |pmid=11739341 |doi= |url=}}</ref><ref name="pmid4006491">{{cite journal |vauthors=Tierney WM, Roth BJ, Psaty B, McHenry R, Fitzgerald J, Stump DL, Anderson FK, Ryder KW, McDonald CJ, Smith DM |title=Predictors of myocardial infarction in emergency room patients |journal=Crit. Care Med. |volume=13 |issue=7 |pages=526–31 |date=July 1985 |pmid=4006491 |doi= |url=}}</ref><ref name="pmid17101942">{{cite journal |vauthors=Sequist TD, Marshall R, Lampert S, Buechler EJ, Lee TH |title=Missed opportunities in the primary care management of early acute ischemic heart disease |journal=Arch. Intern. Med. |volume=166 |issue=20 |pages=2237–43 |date=November 2006 |pmid=17101942 |doi=10.1001/archinte.166.20.2237 |url=}}</ref><ref name="pmid1739527">{{cite journal |vauthors=Norell M, Lythall D, Coghlan G, Cheng A, Kushwaha S, Swan J, Ilsley C, Mitchell A |title=Limited value of the resting electrocardiogram in assessing patients with recent onset chest pain: lessons from a chest pain clinic |journal=Br Heart J |volume=67 |issue=1 |pages=53–6 |date=January 1992 |pmid=1739527 |pmc=1024701 |doi= |url=}}</ref><ref name="pmid16868579">{{cite journal |vauthors=Law K, Elley R, Tietjens J, Mann S |title=Troponin testing for chest pain in primary healthcare: a survey of its use by general practitioners in New Zealand |journal=N. Z. Med. J. |volume=119 |issue=1238 |pages=U2082 |date=July 2006 |pmid=16868579 |doi= |url=}}</ref><ref name="pmid9669056">{{cite journal |vauthors=Wilhelmsen L, Rosengren A, Hagman M, Lappas G |title="Nonspecific" chest pain associated with high long-term mortality: results from the primary prevention study in Göteborg, Sweden |journal=Clin Cardiol |volume=21 |issue=7 |pages=477–82 |date=July 1998 |pmid=9669056 |doi= |url=}}</ref><ref name="pmid16461444">{{cite journal |vauthors=Ruigómez A, Rodríguez LA, Wallander MA, Johansson S, Jones R |title=Chest pain in general practice: incidence, comorbidity and mortality |journal=Fam Pract |volume=23 |issue=2 |pages=167–74 |date=April 2006 |pmid=16461444 |doi=10.1093/fampra/cmi124 |url=}}</ref><ref name="pmid17199456">{{cite journal |vauthors=Robinson JG, Wallace R, Limacher M, Sato A, Cochrane B, Wassertheil-Smoller S, Ockene JK, Blanchette PL, Ko MG |title=Elderly women diagnosed with nonspecific chest pain may be at increased cardiovascular risk |journal=J Womens Health (Larchmt) |volume=15 |issue=10 |pages=1151–60 |date=December 2006 |pmid=17199456 |doi=10.1089/jwh.2006.15.1151 |url=}}</ref><ref name="pmid18180659">{{cite journal |vauthors=Geraldine McMahon C, Yates DW, Hollis S |title=Unexpected mortality in patients discharged from the emergency department following an episode of nontraumatic chest pain |journal=Eur J Emerg Med |volume=15 |issue=1 |pages=3–8 |date=February 2008 |pmid=18180659 |doi=10.1097/MEJ.0b013e32827b14cd |url=}}</ref><ref name="pmid20380960">{{cite journal |vauthors=Yelland M, Cayley WE, Vach W |title=An algorithm for the diagnosis and management of chest pain in primary care |journal=Med. Clin. North Am. |volume=94 |issue=2 |pages=349–74 |date=March 2010 |pmid=20380960 |doi=10.1016/j.mcna.2010.01.011 |url=}}</ref><ref name="pmid15956000">{{cite journal |vauthors=Wang WH, Huang JQ, Zheng GF, Wong WM, Lam SK, Karlberg J, Xia HH, Fass R, Wong BC |title=Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis |journal=Arch. Intern. Med. |volume=165 |issue=11 |pages=1222–8 |date=June 2005 |pmid=15956000 |doi=10.1001/archinte.165.11.1222 |url=}}</ref><ref name="pmid10737285">{{cite journal |vauthors=Borzecki AM, Pedrosa MC, Prashker MJ |title=Should noncardiac chest pain be treated empirically? A cost-effectiveness analysis |journal=Arch. Intern. Med. |volume=160 |issue=6 |pages=844–52 |date=March 2000 |pmid=10737285 |doi= |url=}}</ref><ref name="pmid24207111">{{cite journal |vauthors=Wertli MM, Ruchti KB, Steurer J, Held U |title=Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis |journal=BMC Med |volume=11 |issue= |pages=239 |date=November 2013 |pmid=24207111 |pmc=4226211 |doi=10.1186/1741-7015-11-239 |url=}}</ref>
 
<small><small>
'''''Abbreviations:''''' '''ABG ('''[[arterial blood gas]]'''); ACE ('''[[Angiotensin-converting enzyme|angiotensin converting enzyme]]'''); BMI ('''[[body mass index]]'''); CBC ('''[[Complete blood counts|complete blood count]]'''); CSF ('''[[cerebrospinal fluid]]'''); CXR ('''[[chest X-ray]]'''); ECG ('''[[electrocardiogram]]'''); FEF ('''[[Spirometry|forced expiratory flow rate]]'''); FEV1 ('''[[forced expiratory volume]]'''); FVC ('''[[forced vital capacity]]'''); JVD ('''[[jugular vein distention]]''');''' '''MCV ('''[[mean corpuscular volume]]'''); Plt ('''[[platelet]]'''); RV ('''[[residual volume]]'''); SIADH ('''[[syndrome of inappropriate antidiuretic hormone]]'''); TSH ('''[[thyroid stimulating hormone]]'''); Vt ('''[[tidal volume]]''');''' '''WBC ('''[[White blood cells|white blood cell]]'''); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonance — CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning'''   
 
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="3" |Differentials on the Basis of Etiology
! rowspan="3" |Disease
! colspan="10" |Clinical Manifestations
! colspan="4" |Diagnosis
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! colspan="8" |Symptoms
! rowspan="2" |Risk Factors
! rowspan="2" |Physical Exam
! rowspan="2" |Lab Findings
! rowspan="2" |EKG
! rowspan="2" |Imaging
! rowspan="2" |Gold Standard
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Onset
!Duration
!Quality of Pain
!Cough
!Fever
!Dyspnea
!Weight Loss
!Associated Features
|- style="background: #DCDCDC; padding: 5px;" |
|
!'''[[Stable Angina]]'''<ref name="pmid23166211">{{cite journal |vauthors=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL |title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=126 |issue=25 |pages=e354–471 |date=December 2012 |pmid=23166211 |doi=10.1161/CIR.0b013e318277d6a0 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Sudden (acute)
| style="background: #F5F5F5; padding: 5px;" |2-10 minutes
| style="background: #F5F5F5; padding: 5px;" |
*Heaviness/pressure/ tightness/squeezing/ burning ([[Levine's sign]])
*[[Retrosternal]]  or left sided chest pain
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Nausea and vomiting|Nausea]] and [[vomiting]]
*[[Diaphoresis]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Dyslipidemia]], [[hypertension]], smoking,  family history of premature disease, and [[diabetes]]
| style="background: #F5F5F5; padding: 5px;" |
*Transient [[third heart sound]] [[S3|(S3]] - [[Ventricular|ventricular filling sound]]) and [[fourth heart sound]] ([[S4]] - [[atrial]] filling sound)
| style="background: #F5F5F5; padding: 5px;" |
*[[Cardiac enzymes]] normal
| style="background: #F5F5F5; padding: 5px;" |
*Exercise EKG: ST-segment depression
| style="background: #F5F5F5; padding: 5px;" |
*Exercise Stress Testing: Decreased [[myocardial]] perfusion
*[[Transthoracic echocardiography]]: [[Ejection fraction]] <50 percent
| style="background: #F5F5F5; padding: 5px;" |
*[[Coronary angiography]]
|- style="background: #DCDCDC; padding: 5px;" |
|
!'''[[Unstable Angina]]'''<ref name="pmid8998090">{{cite journal |vauthors=Tatum JL, Jesse RL, Kontos MC, Nicholson CS, Schmidt KL, Roberts CS, Ornato JP |title=Comprehensive strategy for the evaluation and triage of the chest pain patient |journal=Ann Emerg Med |volume=29 |issue=1 |pages=116–25 |date=January 1997 |pmid=8998090 |doi= |url=}}</ref><ref name="pmid10492848">{{cite journal |vauthors=Ornato JP |title=Chest pain emergency centers: improving acute myocardial infarction care |journal=Clin Cardiol |volume=22 |issue=8 Suppl |pages=IV3–9 |date=August 1999 |pmid=10492848 |doi= |url=}}</ref><ref name="pmid7611601">{{cite journal |vauthors=Gibler WB |title=Evaluation of chest pain in the emergency department |journal=Ann. Intern. Med. |volume=123 |issue=4 |pages=315; author reply 317–8 |date=August 1995 |pmid=7611601 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]]
| style="background: #F5F5F5; padding: 5px;" |10-20 minutes
| style="background: #F5F5F5; padding: 5px;" |
*Same as stable angina but often more severe
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Nausea and vomiting]]
*[[Diaphoresis]]
*[[Presyncope]]
*[[Palpitation|Palpitations]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Dyslipidemia]], [[hypertension]], smoking,  family history of premature disease, and [[diabetes]]
| style="background: #F5F5F5; padding: 5px;" |
*Reverse [[Splitting of S2|splitting]] of the [[second heart sound]]
*[[Rales/Crackles|Rales or crackles]]
*[[Elevated jugular venous pressure]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Cardiac Biomarkers|Cardiac biomarkers [Cardiac troponin I, cardiac troponin T]] and [[CK MB|<nowiki>MB isoenzyme of creatine kinase (CK-MB)]</nowiki>]] normal
| style="background: #F5F5F5; padding: 5px;" |
*[[ST-depression]]
*New [[T wave]] inversions
*Transient [[ST-elevation]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Echocardiography]]: [[Ejection fraction]] <50 percent
*Exercise Stress Testing: Decreased [[myocardial]] perfusion
| style="background: #F5F5F5; padding: 5px;" |
*Invasive [[coronary angiography]]
|- style="background: #DCDCDC; padding: 5px;" |
|
!'''[[Myocardial Infarction]]'''<ref name="pmid8704488">{{cite journal |vauthors=Svavarsdóttir AE, Jónasson MR, Gudmundsson GH, Fjeldsted K |title=Chest pain in family practice. Diagnosis and long-term outcome in a community setting |journal=Can Fam Physician |volume=42 |issue= |pages=1122–8 |date=June 1996 |pmid=8704488 |pmc=2146490 |doi= |url=}}</ref><ref name="pmid8163958">{{cite journal |vauthors=Klinkman MS, Stevens D, Gorenflo DW |title=Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network |journal=J Fam Pract |volume=38 |issue=4 |pages=345–52 |date=April 1994 |pmid=8163958 |doi= |url=}}</ref><ref name="pmid19883149">{{cite journal |vauthors=Bösner S, Becker A, Haasenritter J, Abu Hani M, Keller H, Sönnichsen AC, Karatolios K, Schaefer JR, Seitz G, Baum E, Donner-Banzhoff N |title=Chest pain in primary care: epidemiology and pre-work-up probabilities |journal=Eur J Gen Pract |volume=15 |issue=3 |pages=141–6 |date= 2009 |pmid=19883149 |doi=10.3109/13814780903329528 |url=}}</ref><ref name="pmid21391528">{{cite journal |vauthors=Ebell MH |title=Evaluation of chest pain in primary care patients |journal=Am Fam Physician |volume=83 |issue=5 |pages=603–5 |date=March 2011 |pmid=21391528 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]]
| style="background: #F5F5F5; padding: 5px;" |Commonly > 20 minutes
| style="background: #F5F5F5; padding: 5px;" |
*Same as [[stable angina]] but often more severe
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Nausea and vomiting]]
*[[Diaphoresis]]
*[[Presyncope]]
*[[Palpitation|Palpitations]]
*[[Lateral]] [[displacement]] of the [[apical impulse]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Dyslipidemia]], [[hypertension]], smoking,  family history of premature disease, and [[diabetes]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Hypotension]]
*[[Tachycardia]]
*[[S4]] [[Gallop rhythm|gallop]]
*[[Paradoxical splitting of S2]]
*[[Mitral regurgitation]] [[Heart murmur|murmur]]
| style="background: #F5F5F5; padding: 5px;" |
*Elevated [[cardiac enzymes]]
*↑[[Brain natriuretic peptide|B-Type Natriuretic Peptide]]
| style="background: #F5F5F5; padding: 5px;" |
*ST elevation MI (STEMI)
*Non-ST elevation MI (NSTEMI) or Non [[Q wave]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Echocardiography]]: ↓ EF
*CCTA: [[Coronory artery]] stenosis
*CMRI: Coronory vessels [[stenosis]]
*MPI on SPECT or PET scanning: Decreased [[myocardial]] perfusion.
| style="background: #F5F5F5; padding: 5px;" |
*CCTA combined with MPI
|- style="background: #DCDCDC; padding: 5px;" |
! rowspan="9" |Cardiac
![[Vasospastic]]/ Prinzmetal/ Variant Angina<ref name="pmid14434946">{{cite journal |vauthors=PRINZMETAL M, KENNAMER R, MERLISS R, WADA T, BOR N |title=Angina pectoris. I. A variant form of angina pectoris; preliminary report |journal=Am. J. Med. |volume=27 |issue= |pages=375–88 |date=September 1959 |pmid=14434946 |doi= |url=}}</ref><ref name="pmid3779913">{{cite journal |vauthors=Kaski JC, Crea F, Meran D, Rodriguez L, Araujo L, Chierchia S, Davies G, Maseri A |title=Local coronary supersensitivity to diverse vasoconstrictive stimuli in patients with variant angina |journal=Circulation |volume=74 |issue=6 |pages=1255–65 |date=December 1986 |pmid=3779913 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Gradual in onset and offset
| style="background: #F5F5F5; padding: 5px;" |Episodic, gradual in onset and offset
| style="background: #F5F5F5; padding: 5px;" |
*Chest discomfort described as squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, a band-like sensation, knot in the center of the chest, lump in the throat, ache, and heavy weight on chest
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* [[Nausea]], [[diaphoresis]], [[dizziness]], [[dyspnea]], and [[palpitations]]
* Associated with other vasospastic disorders, such as [[Raynaud's phenomenon]] and [[migraine]] [[headache]]
| style="background: #F5F5F5; padding: 5px;" |
* Multiple drugs (ephedrine-based products, [[cocaine]], [[marijuana]], alcohol, butane, sumatriptan, and amphetamines)
* Food-born [[botulism]]
* Guide wire or balloon dilatation while doing PCI
* [[Magnesium]] deficiency
| style="background: #F5F5F5; padding: 5px;" |
*[[Tachycardia]], [[hypertension]], [[diaphoresis]], and a gallop rhythm 
| style="background: #F5F5F5; padding: 5px;" |
* Urine drug screen may be positive for [[cocaine]] or other drugs
| style="background: #F5F5F5; padding: 5px;" |
* Transient (less than 15 minutes) ischemic ST changes in multiple leads
* A tall and broad [[R wave]],
* Disappearance of the [[S wave]]
* A taller T wave
* Negative [[U waves]]
| style="background: #F5F5F5; padding: 5px;" |
* Stress testing: normal noninvasive stress test, exercise-induced spasm with ST-segment elevation,
* [[Stress echocardiography]] with ergonovine provocation: [[Vasospasm]] of [[coronory vessels]]
* Coronary arteriography: [[Epicardial]] spasm
| style="background: #F5F5F5; padding: 5px;" |
* [[Coronary arteriography]]
|- style="background: #DCDCDC; padding: 5px;" |
!'''[[Aortic Dissection]]'''<ref name="pmid28847596">{{cite journal |vauthors=Takagi H, Ando T, Umemoto T |title=Meta-Analysis of Circadian Variation in the Onset of Acute Aortic Dissection |journal=Am. J. Cardiol. |volume=120 |issue=9 |pages=1662–1666 |date=November 2017 |pmid=28847596 |doi=10.1016/j.amjcard.2017.07.067 |url=}}</ref><ref name="pmid11922269">{{cite journal |vauthors=Kojima S, Sumiyoshi M, Nakata Y, Daida H |title=Triggers and circadian distribution of the onset of acute aortic dissection |journal=Circ. J. |volume=66 |issue=3 |pages=232–5 |date=March 2002 |pmid=11922269 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Sudden severe progressive pain (common) or [[chronic]] (rare)
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
* Tearing, ripping sensation, knife like
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Focal neurologic deficit]]
*[[Hypotension]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Hypertension]]
* Genetically mediated [[collagen disorders]]
* Preexisting [[aortic aneurysm]]
* [[Bicuspid aortic valve]]
* [[Aortic coarctation]]
* [[Turner syndrome]]
* [[Vasculitis]] ([[giant cell arteritis]], [[Takayasu arteritis]], [[rheumatoid arthritis]], [[syphilitic aortitis]])
| style="background: #F5F5F5; padding: 5px;" |
*[[Pulse]] deficit
*New [[Diastolic murmurs|diastolic murmur]]
*[[Diastolic]] decrescendo [[Heart murmur|murmur]]
*[[Focal neurologic deficit]]
*[[Hypotension]]
| style="background: #F5F5F5; padding: 5px;" |
* [[D-dimer]] <500 ng/mL rules out [[aortic dissection]]
* ↑Soluble ST2 (sST2)
* Measurements of soluble elastin fragments, smooth muscle [[myosin heavy chain]], high-sensitivity [[C-reactive protein (CRP)|C-reactive protein]], [[fibrinogen]], and [[Fibrillin|fibrillin fragments]]
| style="background: #F5F5F5; padding: 5px;" |
* Nonspecific ST and T wave changes
| style="background: #F5F5F5; padding: 5px;" |
*CXR: [[Mediastinal]] and/or [[aortic widening]]
*CTA: A compressed [[true lumen]]
*MRA: Detects differential flow between the true and false lumens, widening of the [[aorta]] with a thickened wall
*TEE: [[Intimal]] [[dissection]] flaps, true and false lumens, [[thrombosis]] in the false lumen
*[[Aortography]]: Distortion of the normal contrast column, Flow reversal or stasis into a false channel, Failure of major branches to fill, and [[Aortic]] [[valvular regurgitation]]
| style="background: #F5F5F5; padding: 5px;" |
*[[CT angiography]]
*[[Digital subtraction aortography]] (if high suspicion)
|- style="background: #DCDCDC; padding: 5px;" |
!'''[[Pericarditis]]'''<ref name="pmid15028364">{{cite journal |vauthors=Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R |title=Day-hospital treatment of acute pericarditis: a management program for outpatient therapy |journal=J. Am. Coll. Cardiol. |volume=43 |issue=6 |pages=1042–6 |date=March 2004 |pmid=15028364 |doi=10.1016/j.jacc.2003.09.055 |url=}}</ref><ref name="pmid15001332">{{cite journal |vauthors=Troughton RW, Asher CR, Klein AL |title=Pericarditis |journal=Lancet |volume=363 |issue=9410 |pages=717–27 |date=February 2004 |pmid=15001332 |doi=10.1016/S0140-6736(04)15648-1 |url=}}</ref><ref name="pmid12622586">{{cite journal |vauthors=Spodick DH |title=Acute pericarditis: current concepts and practice |journal=JAMA |volume=289 |issue=9 |pages=1150–3 |date=March 2003 |pmid=12622586 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]] or [[subacute]]
| style="background: #F5F5F5; padding: 5px;" |May last for hours to days
| style="background: #F5F5F5; padding: 5px;" |
*Sharp & localized [[retrosternal]] pain
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Pericardial friction rub]]
| style="background: #F5F5F5; padding: 5px;" |
*[[HIV]]
*[[TB]]
*[[Immunosuppression]]
*[[Acute]] trauma
| style="background: #F5F5F5; padding: 5px;" |
*[[Pericardial friction rub]] heard with the [[diaphragm]] of [[stethoscope]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Leukocytosis]]
*↑[[Cardiac troponin I (cTnI) and T (cTnT)|Troponin level]]
*↑[[Erythrocyte sedimentation rate]]
*↑[[C-reactive protein|C-reactive protein level]]
| style="background: #F5F5F5; padding: 5px;" |
*[[EKG]] changes (typically widespread [[ST segment]] elevation or [[PR depressions]])
| style="background: #F5F5F5; padding: 5px;" |
*[[Chest x-ray]] typically normal
*[[Echocardiogram]]: normal or [[pericardial effusion]]
*[[CT scan]]: Noncalcified [[pericardial]] thickening with [[pericardial effusion]]
*CMR: inflamed [[pericardium]] and [[myocarditis]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Pericardiocentesis]]
*[[Pericardial biopsy]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Pericardial Tamponade]]<ref name="pmid20756103">{{cite journal |vauthors=Ewart W |title=Practical Aids in the Diagnosis of Pericardial Effusion, in Connection with the Question as to Surgical Treatment |journal=Br Med J |volume=1 |issue=1838 |pages=717–21 |date=March 1896 |pmid=20756103 |pmc=2406464 |doi= |url=}}</ref><ref name="pmid26320112">{{cite journal |vauthors=Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W, Achenbach S, Agewall S, Al-Attar N, Angel Ferrer J, Arad M, Asteggiano R, Bueno H, Caforio AL, Carerj S, Ceconi C, Evangelista A, Flachskampf F, Giannakoulas G, Gielen S, Habib G, Kolh P, Lambrinou E, Lancellotti P, Lazaros G, Linhart A, Meurin P, Nieman K, Piepoli MF, Price S, Roos-Hesselink J, Roubille F, Ruschitzka F, Sagristà Sauleda J, Sousa-Uva M, Uwe Voigt J, Luis Zamorano J |title=2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS) |journal=Eur. Heart J. |volume=36 |issue=42 |pages=2921–64 |date=November 2015 |pmid=26320112 |doi=10.1093/eurheartj/ehv318 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]] or [[subacute]]
| style="background: #F5F5F5; padding: 5px;" |May last for hours to days
| style="background: #F5F5F5; padding: 5px;" |
*Sharp and stabbing [[retrosternal]] pain
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Pulsus paradoxus]]
*[[Pericardial friction rub|Pericardial rub]]
| style="background: #F5F5F5; padding: 5px;" |
*[[HIV]]
*[[TB]]
*[[Immunosuppression]]
*Acute trauma
| style="background: #F5F5F5; padding: 5px;" |
*[[Kussmaul's sign|Kussmaul sign]]
*[[Beck's triad (cardiology)|Beck triad]]
*[[Pulsus paradoxus]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Creatine kinase|Creatine kinase and isoenzymes]]
*Abnormal LFTs
*[[Antinuclear antibody|Antinuclear antibody assay]], [[erythrocyte sedimentation rate]] and [[rheumatoid factor]]
*[[HIV testing]]
| style="background: #F5F5F5; padding: 5px;" |EKG findings:
*[[Sinus tachycardia]]
*Low QRS voltage
*[[Electrical alternans]]
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]]: enlarged [[cardiac silhouette]] with clear lung fields
*[[Echocardiography]]: Chamber collapse, Respiratory variation in volumes and flows, [[IVC]] [[plethora]]
*[[Swan-Ganz Catheterization]]: Equilibration of average [[intracardiac]] [[diastolic pressures]] (usually between 10 and 30 mmHg) 
| style="background: #F5F5F5; padding: 5px;" |
*[[Echocardiography]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Myocarditis]]<ref name="pmid3974674">{{cite journal |vauthors=Dec GW, Palacios IF, Fallon JT, Aretz HT, Mills J, Lee DC, Johnson RA |title=Active myocarditis in the spectrum of acute dilated cardiomyopathies. Clinical features, histologic correlates, and clinical outcome |journal=N. Engl. J. Med. |volume=312 |issue=14 |pages=885–90 |date=April 1985 |pmid=3974674 |doi=10.1056/NEJM198504043121404 |url=}}</ref><ref name="pmid17493945">{{cite journal |vauthors=Caforio AL, Calabrese F, Angelini A, Tona F, Vinci A, Bottaro S, Ramondo A, Carturan E, Iliceto S, Thiene G, Daliento L |title=A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis |journal=Eur. Heart J. |volume=28 |issue=11 |pages=1326–33 |date=June 2007 |pmid=17493945 |doi=10.1093/eurheartj/ehm076 |url=}}</ref><ref name="pmid21239404">{{cite journal |vauthors=Ukena C, Mahfoud F, Kindermann I, Kandolf R, Kindermann M, Böhm M |title=Prognostic electrocardiographic parameters in patients with suspected myocarditis |journal=Eur. J. Heart Fail. |volume=13 |issue=4 |pages=398–405 |date=April 2011 |pmid=21239404 |doi=10.1093/eurjhf/hfq229 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]] or [[subacute]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
* Sharp & localized [[retrosternal]] pain reflects associated [[pericarditis]]
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Heart failure]]
*[[Sudden cardiac death]]
*[[Arrythmias]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Ischemic heart disease]]
*[[Valvular heart disease]]
| style="background: #F5F5F5; padding: 5px;" |
*[[S3]] and [[S4]] gallop
*[[Cardiac murmurs]]
*[[Pericardial friction rub]]
| style="background: #F5F5F5; padding: 5px;" |
* Serum [[cardiac troponin]] levels
* ↑ [[BNP]] or NT-proBNP level 
| style="background: #F5F5F5; padding: 5px;" |
*Nonspecific ST changes, single [[atrial]] or [[ventricular]] [[ectopic beats]], complex [[ventricular arrhythmias]]
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]]: Normal to enlarged with or without [[pulmonary]] [[vascular congestion]] and [[pleural effusions]]
*[[Echo]]: Left [[ventricular]] dilation, changes in left [[ventricular]] geometry (eg, development of a more spheroid shape), and wall motion abnormalities
* CMR: T1 and T2 signal intensity consistent with [[edema]], presence of LGE consistent with [[necrosis]] or [[scar]]
* Radionuclide ventriculography: ↓ EF
* [[Cardiac catheterization]]: Assessment of hemodynamic status
| style="background: #F5F5F5; padding: 5px;" |
*[[Endomyocardial biopsy]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Hypertrophic cardiomyopathy]]<ref name="pmid8809524">{{cite journal |vauthors=Elliott PM, Kaski JC, Prasad K, Seo H, Slade AK, Goldman JH, McKenna WJ |title=Chest pain during daily life in patients with hypertrophic cardiomyopathy: an ambulatory electrocardiographic study |journal=Eur. Heart J. |volume=17 |issue=7 |pages=1056–64 |date=July 1996 |pmid=8809524 |doi= |url=}}</ref><ref name="pmid7199403">{{cite journal |vauthors=Pasternac A, Noble J, Streulens Y, Elie R, Henschke C, Bourassa MG |title=Pathophysiology of chest pain in patients with cardiomyopathies and normal coronary arteries |journal=Circulation |volume=65 |issue=4 |pages=778–89 |date=April 1982 |pmid=7199403 |doi= |url=}}</ref><ref name="pmid2295747">{{cite journal |vauthors=Webb JG, Sasson Z, Rakowski H, Liu P, Wigle ED |title=Apical hypertrophic cardiomyopathy: clinical follow-up and diagnostic correlates |journal=J. Am. Coll. Cardiol. |volume=15 |issue=1 |pages=83–90 |date=January 1990 |pmid=2295747 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]] or [[subacute]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |Typical or atypical chest pain
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[HF]]
*[[Arrhythmias]]
*[[Syncope]]
*Acute hemodynamic collapse 
| style="background: #F5F5F5; padding: 5px;" |
* Positive family history of sudden cardiac death
* [[Genetic mutation]]
| style="background: #F5F5F5; padding: 5px;" |
* [[S4]]
* [[Systolic murmurs]]
* LV apical impulse
* Brisk [[carotid pulse]]
* ↑ [[JVP]]
* A [[parasternal lift]]
| style="background: #F5F5F5; padding: 5px;" |Non-specific
| style="background: #F5F5F5; padding: 5px;" |
* Prominent abnormal [[Q waves]]
* [[P wave]] abnormalities
* [[Left axis deviation]]
* Deeply inverted [[T waves]]
| style="background: #F5F5F5; padding: 5px;" |
[[Echocardiography]]:
* [[LV hypertrophy]]
* Systolic anterior motion of the [[mitral valve]],
* [[LVOT obstruction]] 
 
*[[Cardiac catheterization]]
**Pressure gradient
**Augmentation of the gradient
**[[Aortic pressure]]
**[[Left ventricular]] pressure
**Left [[atrial]] or [[pulmonary]] [[capillary wedge pressure]]
*[[Coronary angiography]]
**Obstructive [[epicardial]] [[coronary artery disease]]
**[[Genetic testing]] for [[HCM]]: [[Sarcomere]] [[mutation]] in an athlete with a maximal LV wall thickness in the "grey zone" 
 
| style="background: #F5F5F5; padding: 5px;" |[[Genetic testing]] for HCM
|- style="background: #DCDCDC; padding: 5px;" |
![[Stress cardiomyopathy|Stress (takotsubo)]]
[[Stress cardiomyopathy|Cardiomyopathy]]<ref name="pmid15687136">{{cite journal |vauthors=Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, Maron BJ |title=Acute and reversible cardiomyopathy provoked by stress in women from the United States |journal=Circulation |volume=111 |issue=4 |pages=472–9 |date=February 2005 |pmid=15687136 |doi=10.1161/01.CIR.0000153801.51470.EB |url=}}</ref><ref name="pmid26159108">{{cite journal |vauthors=Krishnamoorthy P, Garg J, Sharma A, Palaniswamy C, Shah N, Lanier G, Patel NC, Lavie CJ, Ahmad H |title=Gender Differences and Predictors of Mortality in Takotsubo Cardiomyopathy: Analysis from the National Inpatient Sample 2009-2010 Database |journal=Cardiology |volume=132 |issue=2 |pages=131–136 |date=July 2015 |pmid=26159108 |doi=10.1159/000430782 |url=}}</ref><ref name="pmid26332547">{{cite journal |vauthors=Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, Cammann VL, Sarcon A, Geyer V, Neumann CA, Seifert B, Hellermann J, Schwyzer M, Eisenhardt K, Jenewein J, Franke J, Katus HA, Burgdorf C, Schunkert H, Moeller C, Thiele H, Bauersachs J, Tschöpe C, Schultheiss HP, Laney CA, Rajan L, Michels G, Pfister R, Ukena C, Böhm M, Erbel R, Cuneo A, Kuck KH, Jacobshagen C, Hasenfuss G, Karakas M, Koenig W, Rottbauer W, Said SM, Braun-Dullaeus RC, Cuculi F, Banning A, Fischer TA, Vasankari T, Airaksinen KE, Fijalkowski M, Rynkiewicz A, Pawlak M, Opolski G, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Crea F, Dichtl W, Franz WM, Empen K, Felix SB, Delmas C, Lairez O, Erne P, Bax JJ, Ford I, Ruschitzka F, Prasad A, Lüscher TF |title=Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy |journal=N. Engl. J. Med. |volume=373 |issue=10 |pages=929–38 |date=September 2015 |pmid=26332547 |doi=10.1056/NEJMoa1406761 |url=}}</ref><ref name="pmid15583228">{{cite journal |vauthors=Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, Rihal CS |title=Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction |journal=Ann. Intern. Med. |volume=141 |issue=11 |pages=858–65 |date=December 2004 |pmid=15583228 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]]
| style="background: #F5F5F5; padding: 5px;" |Commonly > 20 minutes
| style="background: #F5F5F5; padding: 5px;" |
*[[Substernal]] heaviness or tightness
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Setting of physical or emotional stress or critical illness
| style="background: #F5F5F5; padding: 5px;" |Stress
| style="background: #F5F5F5; padding: 5px;" |
*[[Murmurs]] and [[rales]] may be present on [[auscultation]] in the setting of [[Pulmonary edema|acute pulmonary edema]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Catecholamines|Catecholamines transiently elevated]]
*↑TnT level
*↑[[Brain natriuretic peptide|BNP level]]
| style="background: #F5F5F5; padding: 5px;" |
*[[ST segment elevation]]
*[[ST depression]]
*[[QT interval prolongation]], [[T wave inversion]], abnormal [[Q waves]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Radionuclide]] [[myocardial perfusion]] imaging: Transient perfusion abnormalities in the left ventricular apex
| style="background: #F5F5F5; padding: 5px;" |
*[[Ventriculography]] and [[invasive coronary angiography]]
|- style="background: #DCDCDC; padding: 5px;" |
!'''[[Aortic Stenosis]]'''<ref name="pmid3984868">{{cite journal |vauthors=Green SJ, Pizzarello RA, Padmanabhan VT, Ong LY, Hall MH, Tortolani AJ |title=Relation of angina pectoris to coronary artery disease in aortic valve stenosis |journal=Am. J. Cardiol. |volume=55 |issue=8 |pages=1063–5 |date=April 1985 |pmid=3984868 |doi= |url=}}</ref><ref name="pmid16352020">{{cite journal |vauthors=Silaruks S, Clark D, Thinkhamrop B, Sia B, Buxton B, Tonkin A |title=Angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis |journal=Heart Lung Circ |volume=10 |issue=1 |pages=14–23 |date=2001 |pmid=16352020 |doi=10.1046/j.1444-2892.2001.00060.x |url=}}</ref><ref name="pmid9924164">{{cite journal |vauthors=Munt B, Legget ME, Kraft CD, Miyake-Hull CY, Fujioka M, Otto CM |title=Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome |journal=Am. Heart J. |volume=137 |issue=2 |pages=298–306 |date=February 1999 |pmid=9924164 |doi=10.1053/hj.1999.v137.95496 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]], recurrent episodes of [[angina]]
| style="background: #F5F5F5; padding: 5px;" |2-10 minutes
| style="background: #F5F5F5; padding: 5px;" |
*Heaviness/pressure/ tightness/squeezing/ burning ([[Levine's sign]])
*[[Retrosternal]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Dyspnea]] and decreased exercise tolerance
*[[Dizziness]] and [[syncope]]
*[[Angina pectoris]]
| style="background: #F5F5F5; padding: 5px;" |
*[[HTN]]
* Old age
| style="background: #F5F5F5; padding: 5px;" |
*[[S2]] is soft, single and [[Paradoxical splitting of S2|paradoxically split]]
*[[A2]] delayed and tends to occur simultaneously with [[P2]]
*[[Aortic]] [[Ejection murmur|ejection]] click
*[[Fourth heart sound|Fourth heart sound (S4)]] can also be heard
*Crescendo–decrescendo [[Heart murmur|murmur]] 
| style="background: #F5F5F5; padding: 5px;" |
*[[Schistiocytes]] on [[peripheral blood smear]]
| style="background: #F5F5F5; padding: 5px;" |
*Non specific (the voltage of the [[QRS complex]] is increased showing the presence of [[left ventricular hypertrophy]])
| style="background: #F5F5F5; padding: 5px;" |
*[[Echocardiography]]: [[aortic leaflets]] thickened and calcified, ↑ [[pulmonary artery pressure]])
*CMR: [[Myocardial fibrosis]], evaluation of [[aortic]] anatomy and size
*MDCT: Degree of [[aortic valve]] calcification
*PET: Measures active [[mineralization]] which correlates with [[stenosis]] severity
| style="background: #F5F5F5; padding: 5px;" |
**[[Echocardiography]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Heart Failure]]<ref name="pmid12163209">{{cite journal |vauthors=Anker SD, Sharma R |title=The syndrome of cardiac cachexia |journal=Int. J. Cardiol. |volume=85 |issue=1 |pages=51–66 |date=September 2002 |pmid=12163209 |doi= |url=}}</ref><ref name="pmid18440336">{{cite journal |vauthors=Horwich TB, Kalantar-Zadeh K, MacLellan RW, Fonarow GC |title=Albumin levels predict survival in patients with systolic heart failure |journal=Am. Heart J. |volume=155 |issue=5 |pages=883–9 |date=May 2008 |pmid=18440336 |doi=10.1016/j.ahj.2007.11.043 |url=}}</ref><ref name="pmid27656000">{{cite journal |vauthors=Breathett K, Allen LA, Udelson J, Davis G, Bristow M |title=Changes in Left Ventricular Ejection Fraction Predict Survival and Hospitalization in Heart Failure With Reduced Ejection Fraction |journal=Circ Heart Fail |volume=9 |issue=10 |pages= |date=October 2016 |pmid=27656000 |pmc=5082710 |doi=10.1161/CIRCHEARTFAILURE.115.002962 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Subacute]] or [[chronic]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Dull
*Left sided chest pain
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Orthopnea]]
*[[Peripheral edema]]
*[[Hemoptysis]]
| style="background: #F5F5F5; padding: 5px;" |[[Dyslipidemia]], [[hypertension]], smoking,  family history of premature disease, and [[diabetes]]
| style="background: #F5F5F5; padding: 5px;" |
*[[S3]]
*[[Jugular venous pressure|Elevated JVP]]
*[[Peripheral edema]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Hyponatremia]]
* [[Hypoalbuminemia]]
* ↑ [[Brain natriuretic peptide|Serum brain natriuretic peptide (BNP) or NT-proBNP level]]
* A mild elevation in serum [[bilirubin]] (total bilirubin <3 mg/dL)
| style="background: #F5F5F5; padding: 5px;" |
*EKG findings are specific according to each cause of [[heart failure]]
*[[Q waves]], [[ST]] and [[T wave]] abnormalities in patients with prior MI
*New onset [[arrhythmias]] ([[atrial fibrillation]] and [[ventricular tachycardia]])
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]]: [[Cardiomegaly]]
*[[Echocardiography]]: ↓ EF
*[[Right heart catheterization]]: [[Pulmonary capillary wedge pressure]] >20 mmHg, [[right atrial pressure]] ≥12 mmHg) and/or decreased [[cardiac index]] (≤2.2 L/min/m2
| style="background: #F5F5F5; padding: 5px;" |
*[[Echocardiography]]
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="3" |Differentials on the Basis of Etiology
! rowspan="3" |Disease
! colspan="10" |Clinical Manifestations
! colspan="4" |Diagnosis
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
| colspan="8" |Symptoms
| rowspan="2" |Risk Factors
! rowspan="2" |Physical Exam
! rowspan="2" |Lab Findings
! rowspan="2" |EKG
! rowspan="2" |Imaging
! rowspan="2" |Gold Standard
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Onset
!Duration
!Quality of Pain
!Cough
!Fever
!Dyspnea
!Weight Loss
!Associated Features
|- style="background: #DCDCDC; padding: 5px;" |
! rowspan="12" |Pulmonary
!'''[[Pulmonary Embolism]]'''<ref name="pmid17904458">{{cite journal |vauthors=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK |title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II |journal=Am. J. Med. |volume=120 |issue=10 |pages=871–9 |date=October 2007 |pmid=17904458 |pmc=2071924 |doi=10.1016/j.amjmed.2007.03.024 |url=}}</ref><ref name="pmid2332918">{{cite journal |vauthors= |title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED) |journal=JAMA |volume=263 |issue=20 |pages=2753–9 |date=1990 |pmid=2332918 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]]
| style="background: #F5F5F5; padding: 5px;" |May last minutes to hours
| style="background: #F5F5F5; padding: 5px;" |
*Sharp or knifelike or [[pleuritic pain]]
*Localized to side of lesion
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Hemoptysis]]
*History of [[venous thromboembolism]] or [[coagulation]] abnormalities.
| style="background: #F5F5F5; padding: 5px;" | [[Hormone replacement therapy]]
[[Cancer]]
[[Oral contraceptive pills]]
[[Stroke]] 
[[Pregnancy]]
[[Postpartum]] 
Prior history of [[VTE]]
[[Thrombophilia]] 
| style="background: #F5F5F5; padding: 5px;" |
*[[S3]] or [[S4]] [[Gallop rhythm|gallop]]
*Low grade fever
*[[Tachycardia]]
*[[Tachypnea]]
*[[Hypoxia]] 
| style="background: #F5F5F5; padding: 5px;" |
*↑[[D-dimer]] ≥500 ng/mL
*[[Arterial blood gas|Arterial blood gases]] ([[Respiratory alkalosis]])
*↑[[Troponin|Troponin levels]]
*[[Hypercoagulation]] workup
| style="background: #F5F5F5; padding: 5px;" |
*[[Tachycardia]] and nonspecific [[ST-segment]] and [[T-wave]] changes (70 percent)
*S1Q3T3 pattern
*New [[right bundle branch block]]
*Inferior Q-waves (leads II, III, and aVF)
| style="background: #F5F5F5; padding: 5px;" |
*[[Duplex Ultrasonography]]: [[DVT]]
*[[CXR]]: [[Westermark sign]], [[Hampton hump]], [[Palla's sign]]
*[[Echocardiography]]:
** [[RV]] dilation (ratio of apical 4-chamber [[RV]] diameter to [[LV|left ventricle (LV)]] diameter > 0.9)
** [[RV]] systolic dysfunction
*[[Ventilation-Perfusion Scanning]]: High probability
| style="background: #F5F5F5; padding: 5px;" |
*[[CT pulmonary angiography]]
|- style="background: #DCDCDC; padding: 5px;" |
!'''[[Pneumothorax|Spontaneous Pneumothorax]]'''<ref name="pmid3678419">{{cite journal |vauthors=Bense L, Wiman LG, Hedenstierna G |title=Onset of symptoms in spontaneous pneumothorax: correlations to physical activity |journal=Eur J Respir Dis |volume=71 |issue=3 |pages=181–6 |date=September 1987 |pmid=3678419 |doi= |url=}}</ref><ref name="pmid8553937">{{cite journal |vauthors=Seow A, Kazerooni EA, Pernicano PG, Neary M |title=Comparison of upright inspiratory and expiratory chest radiographs for detecting pneumothoraces |journal=AJR Am J Roentgenol |volume=166 |issue=2 |pages=313–6 |date=February 1996 |pmid=8553937 |doi=10.2214/ajr.166.2.8553937 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]]
| style="background: #F5F5F5; padding: 5px;" |May last minutes to hours
| style="background: #F5F5F5; padding: 5px;" |
*Sharp
*Localized [[pleuritic]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Respiratory distress]]
*[[Tachypnea]] 
*Asymmetric lung expansion
*Hyperresonance on [[percussion]]
*Decreased [[tactile fremitus]]
*[[Tachycardia]]
*Cardiac [[apical displacement]]
| style="background: #F5F5F5; padding: 5px;" |
* Smoking
* Positive family history
* [[Marfan syndrome]]
* [[Homocystinuria]]
* [[Thoracic]] [[endometriosis]].
| style="background: #F5F5F5; padding: 5px;" |
*[[Decreased breath sounds]] on involved side
*[[Respiratory sounds|Lung sounds]] transmitted from the unaffected [[hemithorax]] are minimal with [[auscultation]] at the [[midaxillary]] line
*Adventitious lung sounds ([[crackles]], [[wheeze]]; an ipsilateral finding)
*[[Pulsus paradoxus]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Respiratory alkalosis]] on [[Arterial blood gases|ABGs]]
| style="background: #F5F5F5; padding: 5px;" |
*Rightward shift in the mean electrical axis
*Loss of [[precordial]] R waves
*Diminution of the QRS voltage
*Precordial T wave inversions
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]]: White [[visceral]] pleural line on the chest radiograph
*[[CT]]: small amounts of [[intrapleural]] gas, atypical collections of [[pleural]] gas, and loculated pneumothoraces
| style="background: #F5F5F5; padding: 5px;" |
*CT scan
|-
!style="background: #DCDCDC; padding: 5px;" |[[Tension Pneumothorax]]<ref name="pmid8820023">{{cite journal |vauthors=Stark P, Leung A |title=Effects of lobar atelectasis on the distribution of pleural effusion and pneumothorax |journal=J Thorac Imaging |volume=11 |issue=2 |pages=145–9 |date=1996 |pmid=8820023 |doi= |url=}}</ref><ref name="pmid23179505">{{cite journal |vauthors=Jalli R, Sefidbakht S, Jafari SH |title=Value of ultrasound in diagnosis of pneumothorax: a prospective study |journal=Emerg Radiol |volume=20 |issue=2 |pages=131–4 |date=April 2013 |pmid=23179505 |doi=10.1007/s10140-012-1091-7 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]]
| style="background: #F5F5F5; padding: 5px;" |May last minutes to hours
| style="background: #F5F5F5; padding: 5px;" |
*Sharp
*[[Pleuritic]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Hypotension]]
*[[Jugular venous distention]]
*[[Respiratory distress]]
| style="background: #F5F5F5; padding: 5px;" |
*Trauma
| style="background: #F5F5F5; padding: 5px;" |
*[[Decreased breath sounds]] on involved side
*[[Respiratory sounds|Lung sounds]] transmitted from the unaffected [[hemithorax]] are minimal with [[auscultation]] at the [[midaxillary]] line
*Adventitious [[Respiratory sounds|lung sounds]] ([[crackles]], [[wheeze]]; an [[ipsilateral]] finding)
*[[Pulsus paradoxus]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Arterial blood gases|Respiratory alkalosis on ABGs]]
| style="background: #F5F5F5; padding: 5px;" |
*Significant elevation of the ST-T segment from leads V1 to V4
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]]: A distinct shift of the [[mediastinum]] to the [[contralateral]] side, collapse of the [[ipsilateral]] lung, and flattening or inversion of the [[ipsilateral]] [[hemidiaphragm]]
| style="background: #F5F5F5; padding: 5px;" |
*[[CT scan]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Pneumonia]]<ref name="pmid14683661">{{cite journal |vauthors=File TM |title=Community-acquired pneumonia |journal=Lancet |volume=362 |issue=9400 |pages=1991–2001 |date=December 2003 |pmid=14683661 |doi=10.1016/S0140-6736(03)15021-0 |url=}}</ref><ref name="pmid17278083">{{cite journal |vauthors=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=Clin. Infect. Dis. |volume=44 Suppl 2 |issue= |pages=S27–72 |date=March 2007 |pmid=17278083 |doi=10.1086/511159 |url=}}</ref><ref name="pmid25337751">{{cite journal |vauthors=Musher DM, Thorner AR |title=Community-acquired pneumonia |journal=N. Engl. J. Med. |volume=371 |issue=17 |pages=1619–28 |date=October 2014 |pmid=25337751 |doi=10.1056/NEJMra1312885 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]] or [[chronic]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Dull
*Localized to side of lesion
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" |
*[[Altered mental status]]
*[[Tachycardia]]
*Rust-colored [[sputum]]
*Green [[sputum]]
*Red currant-jelly [[sputum]]
*[[Central cyanosis]]
| style="background: #F5F5F5; padding: 5px;" |
* Long hospital stay
* Ill contact exposure
* [[Aspiration]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Wheezing]]
*[[Rhonchi]]
*[[Rales]]
*[[Decreased breath sounds]]
*[[Pleural friction rub]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Arterial blood gases|Arterial blood gas]] : [[Hypoxia]], [[hypoxemia]]
*↑ [[Procalcitonin]]
*[[Leukocytosis]]
*[[Sputum culture|Sputum evaluation]]
*Positive blood cultures
| style="background: #F5F5F5; padding: 5px;" |
*[[Sinus tachycardia]]
*Nonspecific [[ST-segment]] or T-wave changes
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]]: [[Interstitial infiltrates]], [[lobar]] consolidation, [[cavitation]] 
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Tracheitis]]/ [[Bronchitis]]<ref name="pmid8327305">{{cite journal |vauthors=Conley SF, Beste DJ, Hoffmann RG |title=Measles-associated bacterial tracheitis |journal=Pediatr. Infect. Dis. J. |volume=12 |issue=5 |pages=414–5 |date=May 1993 |pmid=8327305 |doi= |url=}}</ref><ref name="pmid15577783">{{cite journal |vauthors=Salamone FN, Bobbitt DB, Myer CM, Rutter MJ, Greinwald JH |title=Bacterial tracheitis reexamined: is there a less severe manifestation? |journal=Otolaryngol Head Neck Surg |volume=131 |issue=6 |pages=871–6 |date=December 2004 |pmid=15577783 |doi=10.1016/j.otohns.2004.06.708 |url=}}</ref><ref name="pmid17015531">{{cite journal |vauthors=Hopkins A, Lahiri T, Salerno R, Heath B |title=Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis |journal=Pediatrics |volume=118 |issue=4 |pages=1418–21 |date=October 2006 |pmid=17015531 |doi=10.1542/peds.2006-0692 |url=}}</ref><ref name="pmid6869336">{{cite journal |vauthors=Liston SL, Gehrz RC, Siegel LG, Tilelli J |title=Bacterial tracheitis |journal=Am. J. Dis. Child. |volume=137 |issue=8 |pages=764–7 |date=August 1983 |pmid=6869336 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Dull
*[[Substernal]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Tachypnea]]
*[[Respiratory distress]]
*[[Hoarseness]]
*[[Dyspnea]]
*[[Cyanosis]]
*[[Sore throat]]
*[[Odynophagia]]
*[[Dysphonia]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Aspiration]]
* [[Pneumonia]]
| style="background: #F5F5F5; padding: 5px;" |
*Inspiratory [[stridor]] (with or without expiratory [[Stridor|stridor)]]
*Nasal flaring
*[[Wheezing]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Gram stain]] of [[exudates]]: [[Neutrophils]]
| style="background: #F5F5F5; padding: 5px;" |
*Peaked P-wave
| style="background: #F5F5F5; padding: 5px;" |
*Radiography of the neck: [[Steeple sign]]
*[[Laryngotracheobronchoscopy]]: a normal [[epiglottis]] with [[subglottic]] narrowing, thick and purulent secretions in the [[trachea]], [[pseudomembranes]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Endoscopy]]
|- style="background: #DCDCDC; padding: 5px;" |
!'''[[Pleuritis]]'''
| style="background: #F5F5F5; padding: 5px;" |[[Acute]] or [[subacute]] or [[chronic]]
| style="background: #F5F5F5; padding: 5px;" |May last minutes to hours
| style="background: #F5F5F5; padding: 5px;" |
*Sharp
*Localized [[pleuritic]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Sharp [[chest pain]] with breathing
*[[Itching]] in sites on the back
*[[Dizziness]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Autoimmune]] conditions
* Infections
| style="background: #F5F5F5; padding: 5px;" |
* [[Tachypnea]]
* [[Tachycardia]] 
*[[Pleural friction rub|Pleural Rubs]]
*Decreased breath sounds
| style="background: #F5F5F5; padding: 5px;" |
*[[Leukocytosis]]
*[[Arterial blood gases|Arterial blood gas (ABG)]]: [[Hypoxia]]
*[[Thoracentesis|Thoracocentesis]]
| style="background: #F5F5F5; padding: 5px;" |
*[[EKG]] done to rule out other causes in differential diagnoses
| style="background: #F5F5F5; padding: 5px;" |
*[[Chest X Ray]]: [[Pleural fluid]] on one or both sides
*[[Computerized tomography]] (CT) scan: [[Pleural effusions]]
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]]
|- style="background: #DCDCDC; padding: 5px;" |
!'''[[Pulmonary Hypertension]]'''<ref name="pmid15006585">{{cite journal |vauthors=Mesquita SM, Castro CR, Ikari NM, Oliveira SA, Lopes AA |title=Likelihood of left main coronary artery compression based on pulmonary trunk diameter in patients with pulmonary hypertension |journal=Am. J. Med. |volume=116 |issue=6 |pages=369–74 |date=March 2004 |pmid=15006585 |doi=10.1016/j.amjmed.2003.11.015 |url=}}</ref><ref name="pmid11591592">{{cite journal |vauthors=Rich S, McLaughlin VV, O'Neill W |title=Stenting to reverse left ventricular ischemia due to left main coronary artery compression in primary pulmonary hypertension |journal=Chest |volume=120 |issue=4 |pages=1412–5 |date=October 2001 |pmid=11591592 |doi= |url=}}</ref><ref name="pmid10190427">{{cite journal |vauthors=Kawut SM, Silvestry FE, Ferrari VA, DeNofrio D, Axel L, Loh E, Palevsky HI |title=Extrinsic compression of the left main coronary artery by the pulmonary artery in patients with long-standing pulmonary hypertension |journal=Am. J. Cardiol. |volume=83 |issue=6 |pages=984–6, A10 |date=March 1999 |pmid=10190427 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]] or [[subacute]] or [[chronic]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*[[Substernal]] pressure like
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Dyspnea]]
*Symptoms of [[right heart failure]] ([[edema]])
*Past history of [[heart murmur]]
*[[Deep venous thrombosis|Deep venous thrombosis (DVT)]]
*[[Arthritis]] or [[Arthralgia|arthralgias]]
*[[Rash]]
| style="background: #F5F5F5; padding: 5px;" |
* Smoking
* [[HF]]
* Heavy [[snoring]]
* [[Morbid obesity]]
| style="background: #F5F5F5; padding: 5px;" |
*The intensity of the [[P2|pulmonic component of the second heart sound (P2]]) may be increased and the [[P2]] may demonstrate fixed or paradoxical [[splitting]]. 
*[[Systolic ejection murmur]]
*A [[S4|right-sided fourth heart sound (S4)]] with a left [[parasternal heave]]
| style="background: #F5F5F5; padding: 5px;" |
*Abnormal [[Arterial blood gases|Arterial blood gas]]
*[[Antinuclear antibody|Antinuclear antibody (ANA) levels]]
*[[Anti-neutrophil cytoplasmic antibody|Antineutrophil cytoplasmic antibody (ANCA)]]
*[[Brain natriuretic peptide|Brain natriuretic peptide (BNP of NT-proBNP)]]
*[[HIV testing]]
*[[Iron deficiency]]
*[[PFTs|Pulmonary Function Testing]]
*[[Polysomnography]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Right axis deviation]]
*An R wave/S wave ratio greater than one in lead V1
*Incomplete or complete [[right bundle branch block]]
*Increased P wave amplitude in lead II (P pulmonale) due to right [[atrial enlargement]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Chest Radiography]]: [[Oligemic]] lung fields 
*[[Echocardiography]]:  [[PASP]] is >50 and the TRV is >3.4
*[[Ventilation-Perfusion (V/Q) Lung Scanning]]: Abnormal
*Right-sided [[cardiac catheterization]]: Mean [[PCWP]] >15 mmHg,
| style="background: #F5F5F5; padding: 5px;" |
*[[Cardiac catheterization]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Pleural Effusion]]<ref name="pmid3757561">{{cite journal |vauthors=Feinsilver SH, Barrows AA, Braman SS |title=Fiberoptic bronchoscopy and pleural effusion of unknown origin |journal=Chest |volume=90 |issue=4 |pages=516–9 |date=October 1986 |pmid=3757561 |doi= |url=}}</ref><ref name="pmid3581930">{{cite journal |vauthors=Collins TR, Sahn SA |title=Thoracocentesis. Clinical value, complications, technical problems, and patient experience |journal=Chest |volume=91 |issue=6 |pages=817–22 |date=June 1987 |pmid=3581930 |doi= |url=}}</ref><ref name="pmid15753638">{{cite journal |vauthors=Venekamp LN, Velkeniers B, Noppen M |title=Does 'idiopathic pleuritis' exist? Natural history of non-specific pleuritis diagnosed after thoracoscopy |journal=Respiration |volume=72 |issue=1 |pages=74–8 |date=2005 |pmid=15753638 |doi=10.1159/000083404 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]] or [[subacute]] or [[chronic]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Dull
*[[Pleuritic]] pain
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" |
*Increasing lower extremity [[edema]]
*[[Orthopnea]]
*[[Paroxysmal nocturnal dyspnea]]
*[[Night sweats]]
*[[Hemoptysis]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Pneumonia]]
| style="background: #F5F5F5; padding: 5px;" |
*Diminished or inaudible [[breath sounds]]
*[[Pleural friction rub]]
*[[Egophony]] (known as "E-to-A" changes)
| style="background: #F5F5F5; padding: 5px;" |
*[[Pleural fluid|Pleural fluid LDH levels above 1000 IU/L]]  [[Complete blood count|Nucleated cells]]
** [[Complete blood count|- Lymphocytosis]]
** [[Complete blood count|- Eosinophilia]]
** [[Complete blood count|- Mesothelial cells]]
*[[Pleural fluid]] culture and [[cytology]]
*[[Pleural fluid]] [[Anti-nuclear antibody|antinuclear antibody]] and [[rheumatoid factor]]
| style="background: #F5F5F5; padding: 5px;" |
*Typically not indicated
| style="background: #F5F5F5; padding: 5px;" |
*[[Chest X Ray]]: [[Pleural fluid]] on one or both sides
*[[Computerized tomography (CT)]] scan: Detects small [[pleural effusions]], ie, less than 10 mL and possibly as little as 2 mL of liquid in the [[pleural space]], Thickening of the [[visceral]] and [[parietal pleura]] 
*MRI: Characterize the content of [[pleural effusions]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Computed tomography]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Asthma]] & [[COPD]]<ref name="pmid19423717">{{cite journal |vauthors=Kuempel ED, Wheeler MW, Smith RJ, Vallyathan V, Green FH |title=Contributions of dust exposure and cigarette smoking to emphysema severity in coal miners in the United States |journal=Am. J. Respir. Crit. Care Med. |volume=180 |issue=3 |pages=257–64 |date=August 2009 |pmid=19423717 |doi=10.1164/rccm.200806-840OC |url=}}</ref><ref name="pmid20884729">{{cite journal |vauthors=Lamprecht B, McBurnie MA, Vollmer WM, Gudmundsson G, Welte T, Nizankowska-Mogilnicka E, Studnicka M, Bateman E, Anto JM, Burney P, Mannino DM, Buist SA |title=COPD in never smokers: results from the population-based burden of obstructive lung disease study |journal=Chest |volume=139 |issue=4 |pages=752–763 |date=April 2011 |pmid=20884729 |pmc=3168866 |doi=10.1378/chest.10-1253 |url=}}</ref><ref name="pmid12412667">{{cite journal |vauthors=Rennard S, Decramer M, Calverley PM, Pride NB, Soriano JB, Vermeire PA, Vestbo J |title=Impact of COPD in North America and Europe in 2000: subjects' perspective of Confronting COPD International Survey |journal=Eur. Respir. J. |volume=20 |issue=4 |pages=799–805 |date=October 2002 |pmid=12412667 |doi= |url=}}</ref><ref name="pmid8430714">{{cite journal |vauthors=Badgett RG, Tanaka DJ, Hunt DK, Jelley MJ, Feinberg LE, Steiner JF, Petty TL |title=Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone? |journal=Am. J. Med. |volume=94 |issue=2 |pages=188–96 |date=February 1993 |pmid=8430714 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]] or [[subacute]] or [[chronic]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Tightness
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" |
*[[Cyanosis]]
| style="background: #F5F5F5; padding: 5px;" |
* Smoking
* [[HF]]
* [[HTN]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Elevated jugular venous pressure|Elevated jugular venous pulse (JVP]])
* [[Hyperinflation]] ([[barrel chest]])
* [[Peripheral edema]]
* [[Clubbing]]
*[[Wheezing]]
*[[Rhonchi]]
*Diffusely decreased [[breath sounds]]
*Coarse [[crackles]] beginning with [[inspiration]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Leukocytosis]]
*[[Eosinophilia]]
*[[Respiratory alkalosis]]
| style="background: #F5F5F5; padding: 5px;" |
*Peaked P-wave
*Reduced amplitude of the [[QRS complexes]]
*[[Multifocal atrial tachycardia]] (MAT)
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]]: [[Hyperinflation]]
*[[Spirometry]]: ↓ [[FEV1]], [[Peak expiratory flow|PEF]], ↓ [[FEV1]]/[[FVC]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Spirometry]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Lung Cancer|Pulmonary Malignancy]]<ref name="pmid25564398">{{cite journal |vauthors=Kocher F, Hilbe W, Seeber A, Pircher A, Schmid T, Greil R, Auberger J, Nevinny-Stickel M, Sterlacci W, Tzankov A, Jamnig H, Kohler K, Zabernigg A, Frötscher J, Oberaigner W, Fiegl M |title=Longitudinal analysis of 2293 NSCLC patients: a comprehensive study from the TYROL registry |journal=Lung Cancer |volume=87 |issue=2 |pages=193–200 |date=February 2015 |pmid=25564398 |doi=10.1016/j.lungcan.2014.12.006 |url=}}</ref><ref name="pmid4813837">{{cite journal |vauthors=Hyde L, Hyde CI |title=Clinical manifestations of lung cancer |journal=Chest |volume=65 |issue=3 |pages=299–306 |date=March 1974 |pmid=4813837 |doi= |url=}}</ref><ref name="pmid2992757">{{cite journal |vauthors=Chute CG, Greenberg ER, Baron J, Korson R, Baker J, Yates J |title=Presenting conditions of 1539 population-based lung cancer patients by cell type and stage in New Hampshire and Vermont |journal=Cancer |volume=56 |issue=8 |pages=2107–11 |date=October 1985 |pmid=2992757 |doi= |url=}}</ref><ref name="pmid15165088">{{cite journal |vauthors=Hiraki A, Ueoka H, Takata I, Gemba K, Bessho A, Segawa Y, Kiura K, Eguchi K, Yoneda T, Tanimoto M, Harada M |title=Hypercalcemia-leukocytosis syndrome associated with lung cancer |journal=Lung Cancer |volume=43 |issue=3 |pages=301–7 |date=March 2004 |pmid=15165088 |doi=10.1016/j.lungcan.2003.09.006 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Chronic
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Dull aching
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Bone pain]]
*[[Fatigue]]
*[[Neurologic dysfunction]]
*[[Superior vena cava syndrome|Superior vena cava (SVC) obstruction]]
*[[Hoarseness]]
*Hemidiaphragm [[paralysis]]
*[[Dysphagia]]
*[[Paraneoplastic syndrome|Paraneoplastic syndromes]]
*[[Hypercalcemia]]
| style="background: #F5F5F5; padding: 5px;" |
* Smoking
* [[Metastasis]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Wheeze]]
*[[Crackles]]
*Depending upon [[complications]] caused by the spread of [[cancer]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Hypercalcemia]]
| style="background: #F5F5F5; padding: 5px;" |
*[[EKG]] may be performed before cancer treatment to identify any pre-existing conditions, or during treatment to check for possible heart damage
| style="background: #F5F5F5; padding: 5px;" |
*[[CXR]] and [[CT scan]]: Mass lesion, [[hilar lymphadenopathy]]
*[[Spirometry]]: ↓[[Tidal volume|Vt]], ↑[[Residual volume|RV]]
*[[Bronchoscopy]]: [[Biopsy]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Bronchoscopy]] 
|- style="background: #DCDCDC; padding: 5px;" |
![[Sarcoidosis]]<ref name="pmid26727158">{{cite journal |vauthors=Ungprasert P, Carmona EM, Utz JP, Ryu JH, Crowson CS, Matteson EL |title=Epidemiology of Sarcoidosis 1946-2013: A Population-Based Study |journal=Mayo Clin. Proc. |volume=91 |issue=2 |pages=183–8 |date=February 2016 |pmid=26727158 |pmc=4744129 |doi=10.1016/j.mayocp.2015.10.024 |url=}}</ref><ref name="pmid11734441">{{cite journal |vauthors=Baughman RP, Teirstein AS, Judson MA, Rossman MD, Yeager H, Bresnitz EA, DePalo L, Hunninghake G, Iannuzzi MC, Johns CJ, McLennan G, Moller DR, Newman LS, Rabin DL, Rose C, Rybicki B, Weinberger SE, Terrin ML, Knatterud GL, Cherniak R |title=Clinical characteristics of patients in a case control study of sarcoidosis |journal=Am. J. Respir. Crit. Care Med. |volume=164 |issue=10 Pt 1 |pages=1885–9 |date=November 2001 |pmid=11734441 |doi=10.1164/ajrccm.164.10.2104046 |url=}}</ref><ref name="pmid15753626">{{cite journal |vauthors=Rizzato G, Tinelli C |title=Unusual presentation of sarcoidosis |journal=Respiration |volume=72 |issue=1 |pages=3–6 |date=2005 |pmid=15753626 |doi=10.1159/000083392 |url=}}</ref><ref name="pmid15281433">{{cite journal |vauthors=Rizzato G, Palmieri G, Agrati AM, Zanussi C |title=The organ-specific extrapulmonary presentation of sarcoidosis: a frequent occurrence but a challenge to an early diagnosis. A 3-year-long prospective observational study |journal=Sarcoidosis Vasc Diffuse Lung Dis |volume=21 |issue=2 |pages=119–26 |date=June 2004 |pmid=15281433 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Chronic
| style="background: #F5F5F5; padding: 5px;" |Days to week
| style="background: #F5F5F5; padding: 5px;" |
*Chest fullness
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Löfgren syndrome]] ([[fever]], bilateral hilar [[lymphadenopathy]] (BHL), and [[Polyarthralgia|polyarthralgias]])
*[[Uveitis]]
*[[Heart block]]
*[[Lymphocytic]] [[meningitis]]
*[[Diabetes insipidus]]
*[[Fatigue]]
*[[Hypercalciuria]]
| style="background: #F5F5F5; padding: 5px;" |
* Black population
* [[Autoimmune]] diseases
| style="background: #F5F5F5; padding: 5px;" |
*Diminished respiratory sounds
| style="background: #F5F5F5; padding: 5px;" |
*↑ [[ACE level]], [[adenosine deaminase]], SAA, sIL2R
*[[Hypercalciuria]]
*Elevated [[1,25-dihydroxyvitamin D]] levels
| style="background: #F5F5F5; padding: 5px;" |
*[[AV block]]
*Prolongation of the [[PR interval]] (first-degree AV block)
*[[Ventricular arrhythmias]] (sustained or nonsustained [[ventricular tachycardia]] and ventricular premature beats [VPBs]) 
*[[Supraventricular arrhythmias]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Chest radiograph]]: [[Bilateral hilar adenopathy]]
*High-resolution CT (HRCT) scanning of the chest: [[Ground glass]] opacification, Hilar and [[mediastinal lymphadenopathy]],    [[Bronchial]] wall thickening
| style="background: #F5F5F5; padding: 5px;" |
*Lung [[Biopsy]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Acute chest syndrome]] ([[Sickle cell anemia|Sickle cell anemia)]]<ref name="pmid9057664">{{cite journal |vauthors=Vichinsky EP, Styles LA, Colangelo LH, Wright EC, Castro O, Nickerson B |title=Acute chest syndrome in sickle cell disease: clinical presentation and course. Cooperative Study of Sickle Cell Disease |journal=Blood |volume=89 |issue=5 |pages=1787–92 |date=March 1997 |pmid=9057664 |doi= |url=}}</ref><ref name="pmid7517723">{{cite journal |vauthors=Castro O, Brambilla DJ, Thorington B, Reindorf CA, Scott RB, Gillette P, Vera JC, Levy PS |title=The acute chest syndrome in sickle cell disease: incidence and risk factors. The Cooperative Study of Sickle Cell Disease |journal=Blood |volume=84 |issue=2 |pages=643–9 |date=July 1994 |pmid=7517723 |doi= |url=}}</ref><ref name="pmid10861320">{{cite journal |vauthors=Vichinsky EP, Neumayr LD, Earles AN, Williams R, Lennette ET, Dean D, Nickerson B, Orringer E, McKie V, Bellevue R, Daeschner C, Manci EA |title=Causes and outcomes of the acute chest syndrome in sickle cell disease. National Acute Chest Syndrome Study Group |journal=N. Engl. J. Med. |volume=342 |issue=25 |pages=1855–65 |date=June 2000 |pmid=10861320 |doi=10.1056/NEJM200006223422502 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute]]
| style="background: #F5F5F5; padding: 5px;" |May last minutes to hours
| style="background: #F5F5F5; padding: 5px;" |
*Chest tightness
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Sickle-cell disease|Sickle cell anemia]]
*Vaso-occlusive [[Crisis (charity)|crisis]]
*[[Pain]] crises 
| style="background: #F5F5F5; padding: 5px;" |
* ↑ [[WBC]]
* ↑ [[Hb]] levels
* ↓ [[fetal hemoglobin]] levels
* Smoking
* Vaso-occlusive pain events
| style="background: #F5F5F5; padding: 5px;" |
*[[Systolic murmurs|Systolic murmur]] may be heard over the entire [[precordium]]
| style="background: #F5F5F5; padding: 5px;" |
*↑[[Erythrocyte sedimentation rate]]
*[[Peripheral blood smear|Peripheral blood smears]]: [[Schistiocytes]]
*↑ [[Reticulocyte count|Reticulocyte count]]
| style="background: #F5F5F5; padding: 5px;" |
*[[EKG]] typically not indicated
| style="background: #F5F5F5; padding: 5px;" |
*Plain radiography of the extremities: [[Avascular necrosis]]
| style="background: #F5F5F5; padding: 5px;" | ---
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="3" |Differentials on the Basis of Etiology
! rowspan="3" |Disease
! colspan="10" |Clinical Manifestations
! colspan="4" |Diagnosis
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
| colspan="8" |Symptoms
| rowspan="2" |Risk Factors
! rowspan="2" |Physical Exam
! rowspan="2" |Lab Findings
! rowspan="2" |EKG
! rowspan="2" |Imaging
! rowspan="2" |Gold Standard
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Onset
!Duration
!Quality of Pain
!Cough
!Fever
!Dyspnea
!Weight Loss
!Associated Features
|- style="background: #DCDCDC; padding: 5px;" |
| rowspan="9" |Gastrointestinal
!'''[[GERD]], [[Peptic Ulcer]]'''<ref name="pmid16928254">{{cite journal |vauthors=Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R |title=The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus |journal=Am. J. Gastroenterol. |volume=101 |issue=8 |pages=1900–20; quiz 1943 |date=August 2006 |pmid=16928254 |doi=10.1111/j.1572-0241.2006.00630.x |url=}}</ref><ref name="pmid15290658">{{cite journal |vauthors=Vakil NB, Traxler B, Levine D |title=Dysphagia in patients with erosive esophagitis: prevalence, severity, and response to proton pump inhibitor treatment |journal=Clin. Gastroenterol. Hepatol. |volume=2 |issue=8 |pages=665–8 |date=August 2004 |pmid=15290658 |doi= |url=}}</ref><ref name="pmid18289194">{{cite journal |vauthors=Giannini EG, Zentilin P, Dulbecco P, Vigneri S, Scarlata P, Savarino V |title=Management strategy for patients with gastroesophageal reflux disease: a comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment |journal=Am. J. Gastroenterol. |volume=103 |issue=2 |pages=267–75 |date=February 2008 |pmid=18289194 |doi=10.1111/j.1572-0241.2007.01659.x |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute (medicine)|Acute]]
| style="background: #F5F5F5; padding: 5px;" |
*Minutes to hours ([[Gastroesophageal reflux disease|gastroesophageal reflux]])
*Prolonged ([[peptic ulcer]])
*5 to 60 minutes
| style="background: #F5F5F5; padding: 5px;" |
*Burning
*[[Substernal]]
*[[Epigastric]]
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" |
*[[Visceral]], [[substernal]], worse with recumbency, no radiation, relief with food, antacids
*[[Hematemesis]] or [[melena]] resulting from [[gastrointestinal bleeding]]
*[[Dyspepsia]]
| style="background: #F5F5F5; padding: 5px;" |
* Prolonged [[NSAIDs]] intake
* Smoking
* Alcohol abuse
* Spicy foods
* [[H-pylori infection]]
| style="background: #F5F5F5; padding: 5px;" |
*Not any auscultatory findings associated with this disease
*[[Enamel]] [[Erosion (dental)|erosion]] or other dental manifestations
| style="background: #F5F5F5; padding: 5px;" |
*↑Serum [[Gastrin]] Level
*[[Secretin Stimulation Test]]
*[[H-Pylori testing]]
| style="background: #F5F5F5; padding: 5px;" |
* [[EKG]] usually normal but may show [[T wave inversions]] in leads V2 through V4 consistent with [[myocardial ischemia]] in patients with [[peptic ulcer]] perforation
| style="background: #F5F5F5; padding: 5px;" |
*Upper [[Gastrointestinal]] [[Endoscopy]]: [[Biopsy]]
*[[Esophageal Manometry]]: To exclude an esophageal motility disorder
*Esophageal impedance pH testing: Monitors esophageal [[pH]]
| style="background: #F5F5F5; padding: 5px;" |
*Upper [[Gastrointestinal]] [[Endoscopy]]
|- style="background: #DCDCDC; padding: 5px;" |
!'''[[Diffuse Esophageal Spasm]]'''<ref name="pmid3826958">{{cite journal |vauthors=Katz PO, Dalton CB, Richter JE, Wu WC, Castell DO |title=Esophageal testing of patients with noncardiac chest pain or dysphagia. Results of three years' experience with 1161 patients |journal=Ann. Intern. Med. |volume=106 |issue=4 |pages=593–7 |date=April 1987 |pmid=3826958 |doi= |url=}}</ref><ref name="pmid20179690">{{cite journal |vauthors=Kahrilas PJ |title=Esophageal motor disorders in terms of high-resolution esophageal pressure topography: what has changed? |journal=Am. J. Gastroenterol. |volume=105 |issue=5 |pages=981–7 |date=May 2010 |pmid=20179690 |pmc=2888528 |doi=10.1038/ajg.2010.43 |url=}}</ref><ref name="pmid17900331">{{cite journal |vauthors=Pandolfino JE, Ghosh SK, Rice J, Clarke JO, Kwiatek MA, Kahrilas PJ |title=Classifying esophageal motility by pressure topography characteristics: a study of 400 patients and 75 controls |journal=Am. J. Gastroenterol. |volume=103 |issue=1 |pages=27–37 |date=January 2008 |pmid=17900331 |doi=10.1111/j.1572-0241.2007.01532.x |url=}}</ref><ref name="pmid18364587">{{cite journal |vauthors=Kahrilas PJ, Ghosh SK, Pandolfino JE |title=Esophageal motility disorders in terms of pressure topography: the Chicago Classification |journal=J. Clin. Gastroenterol. |volume=42 |issue=5 |pages=627–35 |date=2008 |pmid=18364587 |pmc=2895002 |doi=10.1097/MCG.0b013e31815ea291 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute (medicine)|Acute]]
| style="background: #F5F5F5; padding: 5px;" |
*Minutes to hours
*5 to 60 minutes
| style="background: #F5F5F5; padding: 5px;" |
*Burning
*Pressure
*[[Visceral]], spontaneous, [[substernal]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" |
*Associated with cold liquids
*Relief with [[nitroglycerin]]
| style="background: #F5F5F5; padding: 5px;" | ---
| style="background: #F5F5F5; padding: 5px;" | ---
| style="background: #F5F5F5; padding: 5px;" |
*[[Barium swallow]]: Multiple areas of [[spasm]]  throughout the length of the esophagus
*Impedance testing: Higher amplitudes and better transit of swallowed boluses
| style="background: #F5F5F5; padding: 5px;" |
*No ECG findings associated with DES, but ECG is done to exclude [[variant angina]] due to higher concurrent association of variant angina with DES 
| style="background: #F5F5F5; padding: 5px;" |
*Esophageal [[Esophageal motility study|manometry]] : ≥20 percent premature contractions (distal latency <4.5 seconds)
| style="background: #F5F5F5; padding: 5px;" |
* [[Esophageal manometry]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Esophagitis]]<ref name="pmid3605035">{{cite journal |vauthors=Bott S, Prakash C, McCallum RW |title=Medication-induced esophageal injury: survey of the literature |journal=Am. J. Gastroenterol. |volume=82 |issue=8 |pages=758–63 |date=August 1987 |pmid=3605035 |doi= |url=}}</ref><ref name="pmid18763324">{{cite journal |vauthors=Parfitt JR, Jayakumar S, Driman DK |title=Mycophenolate mofetil-related gastrointestinal mucosal injury: variable injury patterns, including graft-versus-host disease-like changes |journal=Am. J. Surg. Pathol. |volume=32 |issue=9 |pages=1367–72 |date=September 2008 |pmid=18763324 |doi= |url=}}</ref><ref name="pmid10738847">{{cite journal |vauthors=Jaspersen D |title=Drug-induced oesophageal disorders: pathogenesis, incidence, prevention and management |journal=Drug Saf |volume=22 |issue=3 |pages=237–49 |date=March 2000 |pmid=10738847 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute (medicine)|Acute]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Burning
*[[Epigastric]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" |
*[[Heartburn]]
*[[Abdominal pain]]
| style="background: #F5F5F5; padding: 5px;" |
* [[HIV]]
* [[Immunosuppression]]
| style="background: #F5F5F5; padding: 5px;" |
*No auscultatory finding
| style="background: #F5F5F5; padding: 5px;" |
*[[Cardiac troponin I (cTnI) and T (cTnT)|Troponin or other cardiac markers]]
*[[Leukopenia]]
*↓[[CD4|CD4 count]] 
*[[Human Immunodeficiency Virus (HIV)|Human immunodeficiency virus (HIV) test]]
| style="background: #F5F5F5; padding: 5px;" |
*ECG is done to rule out [[acute coronary syndrome]]
| style="background: #F5F5F5; padding: 5px;" |
*Double-contrast esophageal [[barium study]] ([[esophagography]])
*[[Endoscopy]]: [[Biopsy]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Endoscopy]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Eosinophilic esophagitis|Eosinophilic Esophagitis]]<ref name="pmid18471509">{{cite journal |vauthors=Kapel RC, Miller JK, Torres C, Aksoy S, Lash R, Katzka DA |title=Eosinophilic esophagitis: a prevalent disease in the United States that affects all age groups |journal=Gastroenterology |volume=134 |issue=5 |pages=1316–21 |date=May 2008 |pmid=18471509 |doi=10.1053/j.gastro.2008.02.016 |url=}}</ref><ref name="pmid12612531">{{cite journal |vauthors=Straumann A, Rossi L, Simon HU, Heer P, Spichtin HP, Beglinger C |title=Fragility of the esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis? |journal=Gastrointest. Endosc. |volume=57 |issue=3 |pages=407–12 |date=March 2003 |pmid=12612531 |doi=10.1067/mge.2003.123 |url=}}</ref><ref name="pmid18407800">{{cite journal |vauthors=Straumann A, Bussmann C, Zuber M, Vannini S, Simon HU, Schoepfer A |title=Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients |journal=Clin. Gastroenterol. Hepatol. |volume=6 |issue=5 |pages=598–600 |date=May 2008 |pmid=18407800 |doi=10.1016/j.cgh.2008.02.003 |url=}}</ref><ref name="pmid19577011">{{cite journal |vauthors=Prasad GA, Alexander JA, Schleck CD, Zinsmeister AR, Smyrk TC, Elias RM, Locke GR, Talley NJ |title=Epidemiology of eosinophilic esophagitis over three decades in Olmsted County, Minnesota |journal=Clin. Gastroenterol. Hepatol. |volume=7 |issue=10 |pages=1055–61 |date=October 2009 |pmid=19577011 |pmc=3026355 |doi=10.1016/j.cgh.2009.06.023 |url=}}</ref><ref name="pmid17764492">{{cite journal |vauthors=Prasad GA, Talley NJ, Romero Y, Arora AS, Kryzer LA, Smyrk TC, Alexander JA |title=Prevalence and predictive factors of eosinophilic esophagitis in patients presenting with dysphagia: a prospective study |journal=Am. J. Gastroenterol. |volume=102 |issue=12 |pages=2627–32 |date=December 2007 |pmid=17764492 |doi=10.1111/j.1572-0241.2007.01512.x |url=}}</ref><ref name="pmid15933677">{{cite journal |vauthors=Desai TK, Stecevic V, Chang CH, Goldstein NS, Badizadegan K, Furuta GT |title=Association of eosinophilic inflammation with esophageal food impaction in adults |journal=Gastrointest. Endosc. |volume=61 |issue=7 |pages=795–801 |date=June 2005 |pmid=15933677 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Burning
*[[Retrosternal]]
*Abdominal
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* [[Dysphagia]]
* Food impaction
* [[GERD]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Allergy|Allergic]] [[Disease|diseases]]
*[[Asthma]]
*[[Rinitis]]
*[[Eczema]]
| style="background: #F5F5F5; padding: 5px;" |
*No auscultatory finding in the this [[disease]]
| style="background: #F5F5F5; padding: 5px;" |
*Elevated [[IgE]] (>114,000 units/L)
*Elevated peripheral [[eosinophils]]
| style="background: #F5F5F5; padding: 5px;" |
*Typically no finding on EKG
| style="background: #F5F5F5; padding: 5px;" |
*[[Barium studies]]: [[Strictures]] and a ringed esophagus
*[[Endoscopy]]: Stacked circular rings ("feline" esophagus)  ●[[Strictures]]  ●Linear furrows  ●Whitish papules 
*[[Esophageal biopsy]]: More than 15 [[Eosinophil granulocyte|eosinophils]] per high-power field
| style="background: #F5F5F5; padding: 5px;" |
*Esophageal [[biopsy]]
|- style="background: #DCDCDC; padding: 5px;" |
![[Esophageal perforation|Esophageal Perforation]]<ref name="pmid2730190">{{cite journal |vauthors=Pate JW, Walker WA, Cole FH, Owen EW, Johnson WH |title=Spontaneous rupture of the esophagus: a 30-year experience |journal=Ann. Thorac. Surg. |volume=47 |issue=5 |pages=689–92 |date=May 1989 |pmid=2730190 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute (medicine)|Acute]]
| style="background: #F5F5F5; padding: 5px;" |Minutes to hours
| style="background: #F5F5F5; padding: 5px;" |
*Burning
*Upper abdominal
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Eating disorder|Eating disorders]] such as [[Bulimia nervosa|bulimia]]
*Repeated episodes of [[retching]] and [[vomiting]] with either recent excessive [[dietary]] or [[Alcohol|alcoho]]<nowiki/>l intake
*[[Subcutaneous emphysema]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Instrumentation]]/surgery
* Penetrating or blunt trauma
* Medications, other ingestions, foreign body
* Violent retching/[[vomiting]]
* Hernia/intestinal [[volvulus]]/obstruction
* [[Inflammatory bowel disease]]
* [[Appendicitis]]
* [[Peptic ulcer disease]]
| style="background: #F5F5F5; padding: 5px;" |
*Mild [[tachycardia]] or [[hypothermia]]
*[[Hamman's crunch|Hamman crunch (crackling sound upon chest auscultation occurs due to pneumomediastinum)]] 
| style="background: #F5F5F5; padding: 5px;" |
*↑Serum [[amylase]]
*↑[[C-reactive protein]] levels
| style="background: #F5F5F5; padding: 5px;" |
*[[EKG]] may be indicated to assess for [[myocardial ischemia]] due to [[Gastrointestinal bleeding|acute gastrointestinal bleeding]], especially if there is coexisting:Cardiovascular disease, significant [[anemia]] and advanced age
| style="background: #F5F5F5; padding: 5px;" |
*Plain chest films or chest [[CT]]: [[Pneumomediastinum]], Free air under the [[diaphragm]],  •[[Pleural effusion]]  •[[Pneumothorax]] (Macklin effect).    •[[Subcutaneous emphysema]]
*Plain abdominal films (or abdominal CT scout film):The appearance of [[pneumoperitoneum]]  -Free air under the diaphragm  -Cupola sign (inverted cup)  -Rigler sign (double-wall sign)  -Psoas sign  -Urachus sign 
| style="background: #F5F5F5; padding: 5px;" |
** Confirmed by water-soluble contrast esophagram
|- style="background: #DCDCDC; padding: 5px;" |
![[Mediastinitis]]<ref name="pmid3045478">{{cite journal |vauthors=Loyd JE, Tillman BF, Atkinson JB, Des Prez RM |title=Mediastinal fibrosis complicating histoplasmosis |journal=Medicine (Baltimore) |volume=67 |issue=5 |pages=295–310 |date=September 1988 |pmid=3045478 |doi= |url=}}</ref><ref name="pmid762913">{{cite journal |vauthors=Feigin DS, Eggleston JC, Siegelman SS |title=The multiple roentgen manifestations of sclerosing mediastinitis |journal=Johns Hopkins Med J |volume=144 |issue=1 |pages=1–8 |date=January 1979 |pmid=762913 |doi= |url=}}</ref><ref name="pmid3539049">{{cite journal |vauthors=Garrett HE, Roper CL |title=Surgical intervention in histoplasmosis |journal=Ann. Thorac. Surg. |volume=42 |issue=6 |pages=711–22 |date=December 1986 |pmid=3539049 |doi= |url=}}</ref><ref name="pmid7774324">{{cite journal |vauthors=Sherrick AD, Brown LR, Harms GF, Myers JL |title=The radiographic findings of fibrosing mediastinitis |journal=Chest |volume=106 |issue=2 |pages=484–9 |date=August 1994 |pmid=7774324 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute (medicine)|Acute]], [[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Retrosternal irritation
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Nonspecific
| style="background: #F5F5F5; padding: 5px;" |
* Infection
* Esophageal perforation
* Post operative complication
| style="background: #F5F5F5; padding: 5px;" |
*Dysphagia
*Dysphonia
*Stridor
*[[Hamman's sign|Hamman sign]]
| style="background: #F5F5F5; padding: 5px;" |
*Positive organisms in sternal [[Culture collection|culture]]
*Leukocytosis
*Positive blood cultures
| style="background: #F5F5F5; padding: 5px;" |
*Diffuse ST elevation
| style="background: #F5F5F5; padding: 5px;" |
*CT: Localize the infection and extent of spread
*MRI: Assesses vascular  involvement and complications
| style="background: #F5F5F5; padding: 5px;" | CT scan
|- style="background: #DCDCDC; padding: 5px;" |
!'''[[Gallstone disease| Cholelithiasis]]'''<ref name="pmid19190960">{{cite journal |vauthors=Fitzgerald JE, White MJ, Lobo DN |title=Courvoisier's gallbladder: law or sign? |journal=World J Surg |volume=33 |issue=4 |pages=886–91 |date=April 2009 |pmid=19190960 |doi=10.1007/s00268-008-9908-y |url=}}</ref><ref name="pmid18000708">{{cite journal |vauthors=Yang MH, Chen TH, Wang SE, Tsai YF, Su CH, Wu CW, Lui WY, Shyr YM |title=Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy |journal=Surg Endosc |volume=22 |issue=7 |pages=1620–4 |date=July 2008 |pmid=18000708 |doi=10.1007/s00464-007-9665-2 |url=}}</ref><ref name="pmid10077048">{{cite journal |vauthors=Prat F, Meduri B, Ducot B, Chiche R, Salimbeni-Bartolini R, Pelletier G |title=Prediction of common bile duct stones by noninvasive tests |journal=Ann. Surg. |volume=229 |issue=3 |pages=362–8 |date=March 1999 |pmid=10077048 |pmc=1191701 |doi= |url=}}</ref><ref name="pmid15332044">{{cite journal |vauthors=Tse F, Barkun JS, Barkun AN |title=The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystectomy |journal=Gastrointest. Endosc. |volume=60 |issue=3 |pages=437–48 |date=September 2004 |pmid=15332044 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute (medicine)|Acute]], [[subacute]]
| style="background: #F5F5F5; padding: 5px;" |Minutes to hours
| style="background: #F5F5F5; padding: 5px;" |
*Burning
*Colicky
*Right upper [[abdomen]]
*Substernal
*[[epigastric]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Obesity]]
*Fertile females in 40's
| style="background: #F5F5F5; padding: 5px;" |
*The presence of a common bile duct stone on transabdominal ultrasound
•Clinical acute cholangitis
•A serum bilirubin greater than 4 mg/dL (68 micromol/L)
| style="background: #F5F5F5; padding: 5px;" |
*Murphy sign negative
*Jaundice
| style="background: #F5F5F5; padding: 5px;" |
*↑ALT
*↑AST
*↑[[Amylase]] levels
*↑ALP
| style="background: #F5F5F5; padding: 5px;" |
*Typically not indicated
| style="background: #F5F5F5; padding: 5px;" |
*Transabdominal [[ultrasound]] (TAUS): shows gallstones
*EUS: Detects biliary sludge
*MRCP: Detects stones >6mm
*Endoscopic Retrograde Cholangiopancreatography (ERCP): Diagnostic and therapeutic removal of stones
|Endoscopic ultrasound and MECP
|- style="background: #DCDCDC; padding: 5px;" |
![[Pancreatitis]]<ref name="pmid6237447">{{cite journal |vauthors=Dickson AP, Imrie CW |title=The incidence and prognosis of body wall ecchymosis in acute pancreatitis |journal=Surg Gynecol Obstet |volume=159 |issue=4 |pages=343–7 |date=October 1984 |pmid=6237447 |doi= |url=}}</ref><ref name="pmid12094843">{{cite journal |vauthors=Yadav D, Agarwal N, Pitchumoni CS |title=A critical evaluation of laboratory tests in acute pancreatitis |journal=Am. J. Gastroenterol. |volume=97 |issue=6 |pages=1309–18 |date=June 2002 |pmid=12094843 |doi=10.1111/j.1572-0241.2002.05766.x |url=}}</ref><ref name="pmid8540502">{{cite journal |vauthors=Fortson MR, Freedman SN, Webster PD |title=Clinical assessment of hyperlipidemic pancreatitis |journal=Am. J. Gastroenterol. |volume=90 |issue=12 |pages=2134–9 |date=December 1995 |pmid=8540502 |doi= |url=}}</ref><ref name="pmid10352598">{{cite journal |vauthors=Lecesne R, Taourel P, Bret PM, Atri M, Reinhold C |title=Acute pancreatitis: interobserver agreement and correlation of CT and MR cholangiopancreatography with outcome |journal=Radiology |volume=211 |issue=3 |pages=727–35 |date=June 1999 |pmid=10352598 |doi=10.1148/radiology.211.3.r99jn08727 |url=}}</ref><ref name="pmid17378903">{{cite journal |vauthors=Stimac D, Miletić D, Radić M, Krznarić I, Mazur-Grbac M, Perković D, Milić S, Golubović V |title=The role of nonenhanced magnetic resonance imaging in the early assessment of acute pancreatitis |journal=Am. J. Gastroenterol. |volume=102 |issue=5 |pages=997–1004 |date=May 2007 |pmid=17378903 |doi=10.1111/j.1572-0241.2007.01164.x |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute (medicine)|Acute]], [[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*[[Epigastric]]
*Upper left side of the [[abdomen]]
*Pressure like
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" |
*Primary [[cirrhosis]]
*[[Primary sclerosing cholangitis]]
*Cystic fibrosis
*Autoimmune diseases
| style="background: #F5F5F5; padding: 5px;" |
* Alcohol abuse
* Smoking
* Genetic predisposition
| style="background: #F5F5F5; padding: 5px;" |
* Tachypnea
*Hypoxemia
*Hypotension
*Cullen's sign
*Grey Turner sign 
| style="background: #F5F5F5; padding: 5px;" |
*↑[[Amylase]] levels
*↑[[Lipase]] levels 
*↑ALT
*↑ALP
*Leukocytosis
| style="background: #F5F5F5; padding: 5px;" |
* T-wave inversion
* ST-segment depression
*  ST-segment elevation rarely
* Q-waves
| style="background: #F5F5F5; padding: 5px;" |
*[[Computed tomography|CT]]: focal or diffuse enlargement of the pancreas
*[[Magnetic resonance imaging|MRI]]: Pancreatic enlargement
| style="background: #F5F5F5; padding: 5px;" |
*CT Scan
|- style="background: #DCDCDC; padding: 5px;" |
![[Hiatal Hernia|Sliding Hiatal Hernia]]<ref name="pmid8899401">{{cite journal |vauthors=Weston AP |title=Hiatal hernia with cameron ulcers and erosions |journal=Gastrointest. Endosc. Clin. N. Am. |volume=6 |issue=4 |pages=671–9 |date=October 1996 |pmid=8899401 |doi= |url=}}</ref><ref name="pmid16472589">{{cite journal |vauthors=Bredenoord AJ, Weusten BL, Timmer R, Smout AJ |title=Intermittent spatial separation of diaphragm and lower esophageal sphincter favors acidic and weakly acidic reflux |journal=Gastroenterology |volume=130 |issue=2 |pages=334–40 |date=February 2006 |pmid=16472589 |doi=10.1053/j.gastro.2005.10.053 |url=}}</ref><ref name="pmid18656819">{{cite journal |vauthors=Kahrilas PJ, Kim HC, Pandolfino JE |title=Approaches to the diagnosis and grading of hiatal hernia |journal=Best Pract Res Clin Gastroenterol |volume=22 |issue=4 |pages=601–16 |date=2008 |pmid=18656819 |pmc=2548324 |doi=10.1016/j.bpg.2007.12.007 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Acute (medicine)|Acute]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*[[Epigastric]]
*Burning
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Obstruction]]
*Cameron [[Ulcer|ulcers]]
*GERD
*Dysphagia
| style="background: #F5F5F5; padding: 5px;" |
* Trauma
* Iatrogenic
* Congenital malformation
| style="background: #F5F5F5; padding: 5px;" |
*Bowel sounds may be heard in the chest
| style="background: #F5F5F5; padding: 5px;" |
*Non specific
| style="background: #F5F5F5; padding: 5px;" |
*T wave inversion in anterior lead.
| style="background: #F5F5F5; padding: 5px;" |
*Barium swallow: At least three rugal folds traversing the diaphragm 
*Upper endoscopy: A greater than 2-cm separation between the squamocolumnar junction and the diaphragmatic impression
*High resolution manometry: The separation of the crural diaphragm from the lower esophageal sphincter (LES) by a pressure trough
| style="background: #F5F5F5; padding: 5px;" |
*Upper endoscopy
*High resolution manometry (for smaller hernias)
|- style="background: #DCDCDC; padding: 5px;" |
| rowspan="6" |Musculoskeletal
![[Costochondritis|Costosternal syndromes (costochondritis)]]<ref name="pmid1247350">{{cite journal |vauthors=Wolf E, Stern S |title=Costosternal syndrome: its frequency and importance in differential diagnosis of coronary heart disease |journal=Arch. Intern. Med. |volume=136 |issue=2 |pages=189–91 |date=February 1976 |pmid=1247350 |doi= |url=}}</ref><ref name="pmid4027804">{{cite journal |vauthors=Fam AG, Smythe HA |title=Musculoskeletal chest wall pain |journal=CMAJ |volume=133 |issue=5 |pages=379–89 |date=September 1985 |pmid=4027804 |pmc=1346531 |doi= |url=}}</ref><ref name="pmid20406787">{{cite journal |vauthors=Bösner S, Becker A, Hani MA, Keller H, Sönnichsen AC, Karatolios K, Schaefer JR, Haasenritter J, Baum E, Donner-Banzhoff N |title=Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis |journal=Fam Pract |volume=27 |issue=4 |pages=363–9 |date=August 2010 |pmid=20406787 |doi=10.1093/fampra/cmq024 |url=}}</ref><ref name="pmid28593100">{{cite journal |vauthors=Zaruba RA, Wilson E |title=IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES |journal=Int J Sports Phys Ther |volume=12 |issue=3 |pages=458–467 |date=June 2017 |pmid=28593100 |pmc=5455195 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Acute, subacute
| style="background: #F5F5F5; padding: 5px;" |Days to weeks
| style="background: #F5F5F5; padding: 5px;" |
*Pressure like on anterior part of chest wall
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*History of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture) 
| style="background: #F5F5F5; padding: 5px;" |
* Trauma
| style="background: #F5F5F5; padding: 5px;" |
*Pain by palpation of tender areas
*Maneuvers, such as the "crowing rooster" and horizontal arm flexion maneuver
| style="background: #F5F5F5; padding: 5px;" |
*Non specific
| style="background: #F5F5F5; padding: 5px;" |
*EKG is done to rule out other cardiovascular causes
| style="background: #F5F5F5; padding: 5px;" |
*CXR: To rule out fracture
|Pain by palpation of tender areas
|- style="background: #DCDCDC; padding: 5px;" |
!Lower rib pain syndromes<ref name="pmid8344569">{{cite journal |vauthors=Scott EM, Scott BB |title=Painful rib syndrome--a review of 76 cases |journal=Gut |volume=34 |issue=7 |pages=1006–8 |date=July 1993 |pmid=8344569 |pmc=1374244 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Chronic
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Aching
*Lower chest
*Upper abdomen
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Common in women with a mean age in the mid-40s
| style="background: #F5F5F5; padding: 5px;" | ---
| style="background: #F5F5F5; padding: 5px;" |
*Hooking maneuver
*Reproduces pain by pressing a tender spot on the costal margin
| style="background: #F5F5F5; padding: 5px;" |
*Non specific
*The workup is done for excluding cardiac disorders and other causes of chest pain
| style="background: #F5F5F5; padding: 5px;" |
*EKG is done to rule out other cardiovascular causes
| style="background: #F5F5F5; padding: 5px;" |
*CXR: To rule out fracture
| style="background: #F5F5F5; padding: 5px;" | ---
|- style="background: #DCDCDC; padding: 5px;" |
!Sternalis syndrome
| style="background: #F5F5F5; padding: 5px;" |Chronic
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |Pressure like pain
*Over the body of sternum
*Sternalis muscle
*Left or middle side of the chest wall
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Heart|Cardiac]] diseases
| style="background: #F5F5F5; padding: 5px;" |
* Daily activities
* Emotional [[distress]]
* [[Anxiety]]
| style="background: #F5F5F5; padding: 5px;" |
*Localized [[tenderness]] is found directly over the body of the sternum or overlying sternalis muscle
| style="background: #F5F5F5; padding: 5px;" |
*No specific diagnostic test for this disease
*The workup is done for excluding cardiac disorders and other causes of chest pain
| style="background: #F5F5F5; padding: 5px;" |
*EKG is done to rule out other cardiovascular causes
| style="background: #F5F5F5; padding: 5px;" |
*[[X-rays|X-ray]] : To rule out fracture
| style="background: #F5F5F5; padding: 5px;" |
*Physical exam
|- style="background: #DCDCDC; padding: 5px;" |
![[Tietze's syndrome]]<ref name="pmid1697801">{{cite journal |vauthors=Aeschlimann A, Kahn MF |title=Tietze's syndrome: a critical review |journal=Clin. Exp. Rheumatol. |volume=8 |issue=4 |pages=407–12 |date=1990 |pmid=1697801 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Acute
| style="background: #F5F5F5; padding: 5px;" |Weeks
| style="background: #F5F5F5; padding: 5px;" |Pressure like pain over
*Costosternal joint
*[[Sternoclavicular articulation|Sternoclavicular]] joint
*[[Costochondral joint|Costochondral]] joint
*Second and third ribs
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Most often involve the areas of 2nd and 3rd ribs
*More common in young adults
*Sternocostoclavicular hyperostosis
*Ankylosing spondylitis
| style="background: #F5F5F5; padding: 5px;" |
* Upper respiratory infections
* Excessive coughing
| style="background: #F5F5F5; padding: 5px;" |
*Painful and localized swelling of the costosternal, [[Sternoclavicular articulation|sternoclavicular]], or [[Costochondral joint|costochondral joints]] most often involving 2nd and 3rd [[ribs]]
| style="background: #F5F5F5; padding: 5px;" |
*No specific diagnostic test for this disease
*The workup is done for excluding cardiac disorders and other causes of chest pain
| style="background: #F5F5F5; padding: 5px;" |
*EKG is done to rule out other cardiovascular causes
| style="background: #F5F5F5; padding: 5px;" |
*[[X-rays|X-ray]]: To rule out fracture
| style="background: #F5F5F5; padding: 5px;" |
*Tests are done to rule out other diseases
|- style="background: #DCDCDC; padding: 5px;" |
![[Xiphoidalgia]]<ref name="pmid13266001">{{cite journal |vauthors=LIPKIN M, FULTON LA, WOLFSON EA |title=The syndrome of the hypersensitive xiphoid |journal=N. Engl. J. Med. |volume=253 |issue=14 |pages=591–7 |date=October 1955 |pmid=13266001 |doi=10.1056/NEJM195510062531403 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Acute
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |Pressure like pain over
*Over the xiphoid process
*Sternum
*Xiphisternal joint
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Symptoms are aggravated by twisting and bending movements
| style="background: #F5F5F5; padding: 5px;" |
* Cough
* Heavy work
| style="background: #F5F5F5; padding: 5px;" |
*Provocative test
| style="background: #F5F5F5; padding: 5px;" |
*No specific diagnostic test for this disease
*The workup is done for excluding cardiac disorders and other causes of chest pain
| style="background: #F5F5F5; padding: 5px;" |
*EKG is done to rule out other cardiovascular causes
| style="background: #F5F5F5; padding: 5px;" |
*X-ray: To rule out fracture
| style="background: #F5F5F5; padding: 5px;" |
*Tests are done to rule out other diseases
|- style="background: #DCDCDC; padding: 5px;" |
!Spontaneous [[sternoclavicular]] [[subluxation]]<ref name="pmid1458785">{{cite journal |vauthors=van Holsbeeck M, van Melkebeke J, Dequeker J, Pennes DR |title=Radiographic findings of spontaneous subluxation of the sternoclavicular joint |journal=Clin. Rheumatol. |volume=11 |issue=3 |pages=376–81 |date=September 1992 |pmid=1458785 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Acute, Chronic
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |Aching pain over [[Sternoclavicular articulation|Sternoclavicular joint]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*More common in middle age [[women]]
*Occurs in dominant hands with repetitive tasks of heavy or moderate quality
| style="background: #F5F5F5; padding: 5px;" |
* Trauma
| style="background: #F5F5F5; padding: 5px;" |
*[[Palpation]] of tender areas
| style="background: #F5F5F5; padding: 5px;" |
*No specific diagnostic test for this disease
*The workup is done for excluding cardiac disorders and other causes of chest pain
| style="background: #F5F5F5; padding: 5px;" |
*EKG is done to rule out other cardiovascular causes
| style="background: #F5F5F5; padding: 5px;" |
*[[X-rays|X-ray]]: Sclerosis of the medial clavicle 
| style="background: #F5F5F5; padding: 5px;" |
*X-ray
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="3" |Differentials on the Basis of Etiology
! rowspan="3" |Disease
! colspan="10" |Clinical Manifestations
! colspan="4" |Diagnosis
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
| colspan="8" |Symptoms
| rowspan="2" |Risk Factors
! rowspan="2" |Physical Exam
! rowspan="2" |Lab Findings
! rowspan="2" |EKG
! rowspan="2" |Imaging
! rowspan="2" |Gold Standard
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Onset
!Duration
!Quality of Pain
!Cough
!Fever
!Dyspnea
!Weight loss
!Associated Features
|- style="background: #DCDCDC; padding: 5px;" |
| rowspan="7" |Rheumatic
![[Fibromyalgia]]<ref name="pmid20380956">{{cite journal |vauthors=Almansa C, Wang B, Achem SR |title=Noncardiac chest pain and fibromyalgia |journal=Med. Clin. North Am. |volume=94 |issue=2 |pages=275–89 |date=March 2010 |pmid=20380956 |doi=10.1016/j.mcna.2010.01.002 |url=}}</ref><ref name="pmid7979843">{{cite journal |vauthors=Disla E, Rhim HR, Reddy A, Karten I, Taranta A |title=Costochondritis. A prospective analysis in an emergency department setting |journal=Arch. Intern. Med. |volume=154 |issue=21 |pages=2466–9 |date=November 1994 |pmid=7979843 |doi= |url=}}</ref><ref name="pmid1543409">{{cite journal |vauthors=Wise CM, Semble EL, Dalton CB |title=Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients |journal=Arch Phys Med Rehabil |volume=73 |issue=2 |pages=147–9 |date=February 1992 |pmid=1543409 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |
*Raynaud phenomenon (RP)
*Deep [[Pain|ache]] and burning pain on
**[[Shoulder|Shoulders]]
**Back of the [[Neck]]
**[[Chest]]
**Lower [[Human back|Back]]
**[[Elbow|Elbows]]
**[[Hip (anatomy)|Hips]]
**Shin
**[[Knee|Knees]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Somatization]]
*[[Depression]]
*IBS
| style="background: #F5F5F5; padding: 5px;" | ---
| style="background: #F5F5F5; padding: 5px;" |
*Presence of [[tenderness]] in soft-tissue anatomic locations
| style="background: #F5F5F5; padding: 5px;" |
*Non specific
*Normal [[Blood, Sweat & Tea|Blood]] and [[Urine|urine test]] (mandatory to rule out other diseases)
| style="background: #F5F5F5; padding: 5px;" |
*P-wave dispersions (Pd)
| style="background: #F5F5F5; padding: 5px;" | ---
| style="background: #F5F5F5; padding: 5px;" | ---
|- style="background: #DCDCDC; padding: 5px;" |
![[Rheumatoid arthritis]]<ref name="pmid23335586">{{cite journal |vauthors=Rodríguez-Henríquez P, Solano C, Peña A, León-Hernández S, Hernández-Díaz C, Gutiérrez M, Pineda C |title=Sternoclavicular joint involvement in rheumatoid arthritis: clinical and ultrasound findings of a neglected joint |journal=Arthritis Care Res (Hoboken) |volume=65 |issue=7 |pages=1177–82 |date=July 2013 |pmid=23335586 |doi=10.1002/acr.21958 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Years
| style="background: #F5F5F5; padding: 5px;" |Symmetrical joint pain in
*Wrist
*Fingers
*[[Knee|Knees]]
*Feet
*Ankles
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
*Extra-articular involvement of other organ systems
*[[Carpal tunnel syndrome]]
*[[Tarsal tunnel syndrome]]
| style="background: #F5F5F5; padding: 5px;" |
* Old age
* Smoking
* Autoimmune conditions
| style="background: #F5F5F5; padding: 5px;" |
*Reduced grip strength
*[[Rheumatoid nodules]]
| style="background: #F5F5F5; padding: 5px;" |
*Positive Rheumatic Factor
*Anti-CCP body 
*Synovial fluid analysis: WBC between 1500 and 25,000/cubicmm, low glucose, low C3 and C4 complement level.
*Thrombocytosis
*Anemia
*Mild leukocytosis
| style="background: #F5F5F5; padding: 5px;" |
*ECG is done rule out the heart failure as RA is one of the causes of heart failure
| style="background: #F5F5F5; padding: 5px;" |
*Plain film radiography: periarticular osteopenia, joint space narrowing, and bone erosions
*MRI: Bone erosions
*Ultrasonography: Degree of inflammation and the volume of inflamed tissue
| style="background: #F5F5F5; padding: 5px;" | ---
|- style="background: #DCDCDC; padding: 5px;" |
![[Ankylosing spondylitis]]<ref name="pmid22798267">{{cite journal |vauthors=Ramonda R, Lorenzin M, Lo Nigro A, Vio S, Zucchetta P, Frallonardo P, Campana C, Oliviero F, Modesti V, Punzi L |title=Anterior chest wall involvement in early stages of spondyloarthritis: advanced diagnostic tools |journal=J. Rheumatol. |volume=39 |issue=9 |pages=1844–9 |date=September 2012 |pmid=22798267 |doi=10.3899/jrheum.120107 |url=}}</ref><ref name="pmid23678156">{{cite journal |vauthors=Wendling D, Prati C, Demattei C, Loeuille D, Richette P, Dougados M |title=Anterior chest wall pain in recent inflammatory back pain suggestive of spondyloarthritis. data from the DESIR cohort |journal=J. Rheumatol. |volume=40 |issue=7 |pages=1148–52 |date=July 2013 |pmid=23678156 |doi=10.3899/jrheum.121460 |url=}}</ref><ref name="pmid1488919">{{cite journal |vauthors=Jurik AG |title=Seronegative anterior chest wall syndromes. A study of the findings and course at radiography |journal=Acta Radiol Suppl |volume=381 |issue= |pages=1–42 |date=1992 |pmid=1488919 |doi= |url=}}</ref><ref name="pmid19604431">{{cite journal |vauthors=Guglielmi G, Cascavilla A, Scalzo G, Salaffi F, Grassi W |title=Imaging of sternocostoclavicular joint in spondyloarthropaties and other rheumatic conditions |journal=Clin. Exp. Rheumatol. |volume=27 |issue=3 |pages=402–8 |date=2009 |pmid=19604431 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Years
| style="background: #F5F5F5; padding: 5px;" |Intermittent pain in
*[[Vertebral column|Spine]] joint
*[[Sacroiliac joint|Sacroiliac]] joint
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Patients with [[Human leukocyte antigen|HLA]]-27 variant
*Extra-articular joint involvements
*[[Restrictive lung disease|Restrictive pulmonary disease]]
*Acute coronary syndromes (ACS), strokes, venous thromboembolism, conduction abnormalities
| style="background: #F5F5F5; padding: 5px;" |
* Genetics (Monozygotic twins)
| style="background: #F5F5F5; padding: 5px;" |
*[[Tenderness]] of the SI
*Limited spinal [[Range of motion|ROM]]
*[[Schober's test|Schober test]]
| style="background: #F5F5F5; padding: 5px;" |
*↑ESR
*↑CRP
*↑ALP
*↑IgA
*[[Antigen]] HLA-27 positive
*Negative Rheumatic Factor
| style="background: #F5F5F5; padding: 5px;" |
*ECG is done to rule out conductions defects and aortic insufficiency
| style="background: #F5F5F5; padding: 5px;" |
*Plain radiography: Erosions, ankylosis, changes in joint width, or sclerosis.
*Magnetic resonance imaging (MRI): Osteitis" or "bone marrow edema" (BME)
| style="background: #F5F5F5; padding: 5px;" |
*Plain films of the sacroiliac joints
|- style="background: #DCDCDC; padding: 5px;" |
![[Psoriatic arthritis]]<ref name="pmid1488919">{{cite journal |vauthors=Jurik AG |title=Seronegative anterior chest wall syndromes. A study of the findings and course at radiography |journal=Acta Radiol Suppl |volume=381 |issue= |pages=1–42 |date=1992 |pmid=1488919 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Years
| style="background: #F5F5F5; padding: 5px;" |Asymmetrical intermittent pain in
*[[Interphalangeal articulations of hand|Interphalangeal joints]]
*Nails
*Wrist
*[[Knee|Knees]]
*Ankles
*Lower [[Human back|Back]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Psoriasis]]
*[[Enthesitis]]
*[[Tenosynovitis]]
*[[Dactylitis]]
| style="background: #F5F5F5; padding: 5px;" |
* Psoriasis
* HLA-B*27 positive
| style="background: #F5F5F5; padding: 5px;" |
*[[Dactylitis]] with sausage [[digits]] 
*Onycholysis
*Pitting edema
*Ocular involvement
| style="background: #F5F5F5; padding: 5px;" |Non specific
| style="background: #F5F5F5; padding: 5px;" |
*Longer PR interval 
| style="background: #F5F5F5; padding: 5px;" |
*X-ray: "pencil-in-cup" deformity, erosive changes and new bone formation, lysis of the terminal phalanges; fluffy periostitis
*MRI: Detects articular, periarticular, and soft-tissue inflammation, enthesitis
| style="background: #F5F5F5; padding: 5px;" |
*X-ray
|- style="background: #DCDCDC; padding: 5px;" |
!Sternocostoclavicular [[hyperostosis]] (SAPHO syndrome)<ref name="pmid1488919">{{cite journal |vauthors=Jurik AG |title=Seronegative anterior chest wall syndromes. A study of the findings and course at radiography |journal=Acta Radiol Suppl |volume=381 |issue= |pages=1–42 |date=1992 |pmid=1488919 |doi= |url=}}</ref><ref name="pmid8484129">{{cite journal |vauthors=Saghafi M, Henderson MJ, Buchanan WW |title=Sternocostoclavicular hyperostosis |journal=Semin. Arthritis Rheum. |volume=22 |issue=4 |pages=215–23 |date=February 1993 |pmid=8484129 |doi= |url=}}</ref><ref name="pmid19772827">{{cite journal |vauthors=Magrey M, Khan MA |title=New insights into synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome |journal=Curr Rheumatol Rep |volume=11 |issue=5 |pages=329–33 |date=October 2009 |pmid=19772827 |doi= |url=}}</ref><ref name="pmid19479702">{{cite journal |vauthors=Colina M, Govoni M, Orzincolo C, Trotta F |title=Clinical and radiologic evolution of synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome: a single center study of a cohort of 71 subjects |journal=Arthritis Rheum. |volume=61 |issue=6 |pages=813–21 |date=June 2009 |pmid=19479702 |doi=10.1002/art.24540 |url=}}</ref><ref name="pmid23597971">{{cite journal |vauthors=Carneiro S, Sampaio-Barros PD |title=SAPHO syndrome |journal=Rheum. Dis. Clin. North Am. |volume=39 |issue=2 |pages=401–18 |date=May 2013 |pmid=23597971 |doi=10.1016/j.rdc.2013.02.009 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Years
| style="background: #F5F5F5; padding: 5px;" |Recurrent and multifocal pain in
[[Sternoclavicular articulation|Sternoclavicular]] joint
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Palmoplantar [[pustulosis]] (PPP)
| style="background: #F5F5F5; padding: 5px;" |
Positive family history of:
* Spondyloarthritis
* IBD
* Psoriasis
* Rheumatoid arthritis
* Other autoimmune/autoinflammatory disease
| style="background: #F5F5F5; padding: 5px;" |
*Hyperostosis
*Osteitis
*Synovitis
*Pustular eruptions
*Inflammatory nodules or plaques
| style="background: #F5F5F5; padding: 5px;" |
*[[Serology|Serologic]] testing to exclude other diseases
*Non specific
| style="background: #F5F5F5; padding: 5px;" |
*ECG is done to rule out conductions defects and aortic insufficiency
| style="background: #F5F5F5; padding: 5px;" |
*Plain radiography: Hyperostotic changes (thickening of periosteum, cortex, and endosteum), sclerotic lesions, osteolysis, periosteal reaction, and osteoproliferation
*Bone scan: "bull's head" change
*Magnetic resonance imaging: Osteitis and soft tissue involvement
*Fluorodeoxyglucose positron emission tomography (FDG-PET)/CT: Differentiates active versus inactive lesions 
| style="background: #F5F5F5; padding: 5px;" |
*Bone scan
|- style="background: #DCDCDC; padding: 5px;" |
![[Systemic lupus erythematosus]]<ref name="pmid6749397">{{cite journal |vauthors=Turner-Stokes L, Turner-Warwick M |title=Intrathoracic manifestations of SLE |journal=Clin Rheum Dis |volume=8 |issue=1 |pages=229–42 |date=April 1982 |pmid=6749397 |doi= |url=}}</ref> <ref name="pmid5015911">{{cite journal |vauthors=Hunder GG, McDuffie FC, Hepper NG |title=Pleural fluid complement in systemic lupus erythematosus and rheumatoid arthritis |journal=Ann. Intern. Med. |volume=76 |issue=3 |pages=357–63 |date=March 1972 |pmid=5015911 |doi= |url=}}</ref><ref name="pmid17283581">{{cite journal |vauthors=Porcel JM, Ordi-Ros J, Esquerda A, Vives M, Madroñero AB, Bielsa S, Vilardell-Tarrés M, Light RW |title=Antinuclear antibody testing in pleural fluid for the diagnosis of lupus pleuritis |journal=Lupus |volume=16 |issue=1 |pages=25–7 |date=2007 |pmid=17283581 |doi=10.1177/0961203306074470 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Years
| style="background: #F5F5F5; padding: 5px;" |
*Skin
*[[Joint|Joints]] (fingers, wrist, knees)
*[[Kidney|Kidneys]]
*SLE can affect any organ of the body
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Human leukocyte antigen|HLA]]-genetic mutations
*[[Female]] gender
*Being younger than 50 
| style="background: #F5F5F5; padding: 5px;" |
* Autoimmune conditions
* Genetic predisposition
* Positive family history
| style="background: #F5F5F5; padding: 5px;" |
*[[Malar rash]]
*[[Photosensitive]] [[rash]]
*[[Discoid lupus|Discoid rash]]
*[[Arthritis]] of the [[Proximal interphalangeal joints|proximal interphalangeal (PIP)]] and [[Metacarpophalangeal joint|metacarpophalangeal (MCP) joints]] of the [[hands]]
*[[Pleural friction rub|Pleuro-pericardial friction rubs]]
*[[Systolic murmurs]]
| style="background: #F5F5F5; padding: 5px;" |
*Elevation of [[Autoantibody|autoantibodies]] ([[Antinuclear antibodies|ANA]], [[Anti-dsDNA antibody|anti-dsDNA]], [[Anti-SM antibody|anti-SM]], [[Antiphospholipid antibodies|antiphospholipid]])
*[[Complement]] levels decreased
*Anemia
| style="background: #F5F5F5; padding: 5px;" |
* [[Sinus tachycardia]], [[ST segment changes]], and [[Ventricular arrhythmias|ventricular conduction disturbances]]
| style="background: #F5F5F5; padding: 5px;" |
*Related to specific organ involvent
| style="background: #F5F5F5; padding: 5px;" |
*Anti-dsDNA antibody test
|- style="background: #DCDCDC; padding: 5px;" |
![[Relapsing polychondritis]]<ref name="pmid23597963">{{cite journal |vauthors=Chopra R, Chaudhary N, Kay J |title=Relapsing polychondritis |journal=Rheum. Dis. Clin. North Am. |volume=39 |issue=2 |pages=263–76 |date=May 2013 |pmid=23597963 |doi=10.1016/j.rdc.2013.03.002 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Chronic (medical)|Chronic]]
| style="background: #F5F5F5; padding: 5px;" |Years
| style="background: #F5F5F5; padding: 5px;" |Intermittent pain in:
*[[Tissue (biology)|Tissues]] that cover the end of the [[Joint|joints]]
*[[Cartilage]] of costal rib
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Hodgkin's lymphoma|Hodkin's lymphoma]]
*[[Myelodysplastic syndrome|Myelodysplastic]] syndromes
*[[Digestive disease|Gastrointestinal disorders]]
*Type 1 [[Diabetes mellitus]]
*[[Auricular appendage|Auricular]] [[chondritis]]
| style="background: #F5F5F5; padding: 5px;" |
* Autoimmune diseases
| style="background: #F5F5F5; padding: 5px;" |
*[[Physical examination|Physical examinations]] findings are seen related to [[nasal]] [[chondritis]], [[ocular]] [[inflammation]], [[cardiovascular disease]], [[skin disease]], [[CNS]] and [[Pulmonary|pulmonary system]]
| style="background: #F5F5F5; padding: 5px;" |
*Negative [[Rheumatoid factor|rheumatoid]] factor
*Anti-type II collagen antibodies
*Antineutrophil cytoplasmic antibodies
| style="background: #F5F5F5; padding: 5px;" |
* ECG is done to rule out the cardiovascular complications of this disease
| style="background: #F5F5F5; padding: 5px;" |
*Non specific
*Related to specific organ involvent
| style="background: #F5F5F5; padding: 5px;" |
*No gold standard test for this disease
|- style="background: #DCDCDC; padding: 5px;" |
|Psychiatric
![[Panic attack]]/ Disorder<ref name="pmid10906353">{{cite journal |vauthors=Fleet RP, Martel JP, Lavoie KL, Dupuis G, Beitman BD |title=Non-fearful panic disorder: a variant of panic in medical patients? |journal=Psychosomatics |volume=41 |issue=4 |pages=311–20 |date=2000 |pmid=10906353 |doi=10.1176/appi.psy.41.4.311 |url=}}</ref><ref name="pmid7954018">{{cite journal |vauthors=Fleet RP, Dupuis G, Marchand A, Burelle D, Beitman BD |title=Panic disorder, chest pain and coronary artery disease: literature review |journal=Can J Cardiol |volume=10 |issue=8 |pages=827–34 |date=October 1994 |pmid=7954018 |doi= |url=}}</ref><ref name="pmid8068393">{{cite journal |vauthors=Simpson RJ, Kazmierczak T, Power KG, Sharp DM |title=Controlled comparison of the characteristics of patients with panic disorder |journal=Br J Gen Pract |volume=44 |issue=385 |pages=352–6 |date=August 1994 |pmid=8068393 |pmc=1238951 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Acute or subacute or chronic
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*History of [[Depression]]
*[[Panic attack|Panic attacks]]
*[[Agoraphobia]]
| style="background: #F5F5F5; padding: 5px;" |
*Psychiatric disorders
| style="background: #F5F5F5; padding: 5px;" |
*Anxious
*Tachypneic
| style="background: #F5F5F5; padding: 5px;" |
*Thyroid function tests
*Complete blood count
*Chemistry panel
| style="background: #F5F5F5; padding: 5px;" |
*Sinus Tachycardia
| style="background: #F5F5F5; padding: 5px;" |
*No any specific radiographic test is done
| style="background: #F5F5F5; padding: 5px;" | ---
|- style="background: #DCDCDC; padding: 5px;" |
| rowspan="2" |
Others
!Substance abuse
([[Cocaine abuse|Cocaine]])<ref name="pmid26039070">{{cite journal |vauthors=Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, Pickering RP, Ruan WJ, Smith SM, Huang B, Hasin DS |title=Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III |journal=JAMA Psychiatry |volume=72 |issue=8 |pages=757–66 |date=August 2015 |pmid=26039070 |pmc=5240584 |doi=10.1001/jamapsychiatry.2015.0584 |url=}}</ref><ref name="pmid17592911">{{cite journal |vauthors=Cosci F, Schruers KR, Abrams K, Griez EJ |title=Alcohol use disorders and panic disorder: a review of the evidence of a direct relationship |journal=J Clin Psychiatry |volume=68 |issue=6 |pages=874–80 |date=June 2007 |pmid=17592911 |doi= |url=}}</ref><ref name="pmid2183544">{{cite journal |vauthors=George DT, Nutt DJ, Dwyer BA, Linnoila M |title=Alcoholism and panic disorder: is the comorbidity more than coincidence? |journal=Acta Psychiatr Scand |volume=81 |issue=2 |pages=97–107 |date=February 1990 |pmid=2183544 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Acute (hours)
| style="background: #F5F5F5; padding: 5px;" |Minutes to hours
| style="background: #F5F5F5; padding: 5px;" |Pressure like pain in the center of chest
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
*[[Anxiety]]
*[[Dyspnea]]
*[[Nausea and vomiting|Nausea]]
*[[Palpitation|Palpitations]]
| style="background: #F5F5F5; padding: 5px;" |
*Psychiatric disorders
| style="background: #F5F5F5; padding: 5px;" |
*[[Signs]] of [[injection]] [[drug use]]
*[[Signs]] of [[drug]] [[inhalation]]
*Poor [[personal hygiene]]
| style="background: #F5F5F5; padding: 5px;" |
*Serum [[Cardiac biomarkers|biomarkers]] ([[Troponin I]], [[Troponin T]])
*Toxicologic tests or drug screens of bodily fluids (blood, urine, saliva) and hairs
| style="background: #F5F5F5; padding: 5px;" |
**QT prolongation
**Sinus Tachycardia
**Arrhythmias
**Cardiac conduction abnormalities
| style="background: #F5F5F5; padding: 5px;" | ---
| style="background: #F5F5F5; padding: 5px;" |
*Gold standard test depends on the type of substance is abuse
|- style="background: #DCDCDC; padding: 5px;" |
![[Herpes Zoster]]<ref name="pmid17143845">{{cite journal |vauthors=Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, Betts RF, Gershon AA, Haanpaa ML, McKendrick MW, Nurmikko TJ, Oaklander AL, Oxman MN, Pavan-Langston D, Petersen KL, Rowbotham MC, Schmader KE, Stacey BR, Tyring SK, van Wijck AJ, Wallace MS, Wassilew SW, Whitley RJ |title=Recommendations for the management of herpes zoster |journal=Clin. Infect. Dis. |volume=44 Suppl 1 |issue= |pages=S1–26 |date=January 2007 |pmid=17143845 |doi=10.1086/510206 |url=}}</ref><ref name="pmid8545018">{{cite journal |vauthors=Oxman MN |title=Immunization to reduce the frequency and severity of herpes zoster and its complications |journal=Neurology |volume=45 |issue=12 Suppl 8 |pages=S41–6 |date=December 1995 |pmid=8545018 |doi= |url=}}</ref><ref name="pmid15897984">{{cite journal |vauthors=Jumaan AO, Yu O, Jackson LA, Bohlke K, Galil K, Seward JF |title=Incidence of herpes zoster, before and after varicella-vaccination-associated decreases in the incidence of varicella, 1992-2002 |journal=J. Infect. Dis. |volume=191 |issue=12 |pages=2002–7 |date=June 2005 |pmid=15897984 |doi=10.1086/430325 |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |Acute or Chronic
| style="background: #F5F5F5; padding: 5px;" |Variable
| style="background: #F5F5F5; padding: 5px;" |Burning pain on
*Chest
*Upper back
*Lower back
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*People who had [[chickenpox]]
| style="background: #F5F5F5; padding: 5px;" |
* Immunosuppression
| style="background: #F5F5F5; padding: 5px;" |
*[[Painful]] grouped herpetiform [[vesicles]] on an [[Erythematous|erythematous base]] distributed in a single [[dermatome]]
| style="background: #F5F5F5; padding: 5px;" |
*Viral culture
*Direct immunofluorescence testing,
*Polymerase chain reaction assay (PCR)
| style="background: #F5F5F5; padding: 5px;" |
*ECG is done to rule out other cardiovascular causes of chest pain
| style="background: #F5F5F5; padding: 5px;" |
*Magnetic resonance imaging (MRI): To rule out encephalitis
| style="background: #F5F5F5; padding: 5px;" |
*Viral tissue culture
|}


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
* There are no findings characteristic for vasospastic angina. However, during an episode, tachycardia, hypertension, diaphoresis, and a gallop rhythm may be present.
*Bradycardia and hypotension can be observed if the sinus nodal, atrioventricular nodal, and right ventricular arteries are involved during proximal right coronary artery vasospasm.
* If left untreated, 25% of patients with prinzmetal angina may progress to develop myocardial infarction and life threatening arrhythmias.<ref name="pmid18355592">{{cite journal| author=Kishida H, Tada Y, Tetsuoh Y, Yamazaki Y, Saito T, Fukuma N et al.| title=A new strategy for the reduction of acute myocardial infarction in variant angina. | journal=Am Heart J | year= 1991 | volume= 122 | issue= 6 | pages= 1554-61 | pmid=1835559 | doi=10.1016/0002-8703(91)90271-i | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1835559  }}</ref><ref name="pmid1574091">{{cite journal| author=Myerburg RJ, Kessler KM, Mallon SM, Cox MM, deMarchena E, Interian A et al.| title=Life-threatening ventricular arrhythmias in patients with silent myocardial ischemia due to coronary-artery spasm. | journal=N Engl J Med | year= 1992 | volume= 326 | issue= 22 | pages= 1451-5 | pmid=1574091 | doi=10.1056/NEJM199205283262202 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1574091  }}</ref>
* If left untreated, 25% of patients with prinzmetal angina may progress to develop myocardial infarction and life threatening arrhythmias.<ref name="pmid18355592">{{cite journal| author=Kishida H, Tada Y, Tetsuoh Y, Yamazaki Y, Saito T, Fukuma N et al.| title=A new strategy for the reduction of acute myocardial infarction in variant angina. | journal=Am Heart J | year= 1991 | volume= 122 | issue= 6 | pages= 1554-61 | pmid=1835559 | doi=10.1016/0002-8703(91)90271-i | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1835559  }}</ref><ref name="pmid1574091">{{cite journal| author=Myerburg RJ, Kessler KM, Mallon SM, Cox MM, deMarchena E, Interian A et al.| title=Life-threatening ventricular arrhythmias in patients with silent myocardial ischemia due to coronary-artery spasm. | journal=N Engl J Med | year= 1992 | volume= 326 | issue= 22 | pages= 1451-5 | pmid=1574091 | doi=10.1056/NEJM199205283262202 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1574091  }}</ref>
* Two-thirds of patients have concurrent [[atherosclerosis]] of a major coronary artery. This is often mild or not in proportion to the degree of symptoms.
* Two-thirds of patients have concurrent [[atherosclerosis]] of a major coronary artery. This is often mild or not in proportion to the degree of symptoms.
Line 1,873: Line 75:
==History and Symptoms==
==History and Symptoms==
While the symptoms of chronic stable angina occur with exertion, the symptoms of Prinzmetal's angina typically occur at rest.  The symptoms may occur reproducibly at certain times of the day or night. In the classic description, the symptoms often come on at night.
While the symptoms of chronic stable angina occur with exertion, the symptoms of Prinzmetal's angina typically occur at rest.  The symptoms may occur reproducibly at certain times of the day or night. In the classic description, the symptoms often come on at night.
Characteristic pain features for vasospastic angina include:
*Discomfort better describes the spasms than pain. Other common ways to describe the episodes: squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, a band-like sensation, knot in the center of the chest, lump in the throat, ache, and heavy weight on chest.
*Each episode is typically gradual in onset and offset.
*There is no change in the quality of pain with respiration or position.
*The patient may have some difficulty in describing the location of the pain, although the substernal location is common. Radiation to the neck, throat, lower jaw, teeth, upper extremity, or shoulder is common.
*During each episode, symptoms of nausea, sweating, dizziness, dyspnea, and palpitations may be present.


==Diagnosis==
==Diagnosis==
Line 1,904: Line 113:
**Multiple calcium channel blockers may be required in patients with refractory or multi-vessel spasm.
**Multiple calcium channel blockers may be required in patients with refractory or multi-vessel spasm.
**A patient who has suffered ventricular tachycardia or ventricular fibrillation due to spontaneous [[vasospasm]] (not due to acute infarction) should also likely undergo ICD placement.
**A patient who has suffered ventricular tachycardia or ventricular fibrillation due to spontaneous [[vasospasm]] (not due to acute infarction) should also likely undergo ICD placement.
***Diltiazem 240-360 mg PO qd
***[[Diltiazem]] 240-360 mg PO qd
***Verapamil 240-480 mg PO qd
***[[Verapamil]] 240-480 mg PO qd
***Nifedipine XL 60-120 mg PO qd
***[[Nifedipine]] XL 60-120 mg PO qd
***Nicardipine 40-160 mg PO qd
***[[Nicardipine]] 40-160 mg PO qd
*'''Long-acting nitrate'''s:  
*'''Long-acting nitrate'''s:  
**Generally, well tolerated and can aid with hypertension control.<ref name="pmid3260150">{{cite journal| author=Yasue H, Takizawa A, Nagao M, Nishida S, Horie M, Kubota J et al.| title=Long-term prognosis for patients with variant angina and influential factors. | journal=Circulation | year= 1988 | volume= 78 | issue= 1 | pages= 1-9 | pmid=3260150 | doi=10.1161/01.cir.78.1.1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3260150  }}</ref>
**Generally, well tolerated and can aid with hypertension control.<ref name="pmid3260150">{{cite journal| author=Yasue H, Takizawa A, Nagao M, Nishida S, Horie M, Kubota J et al.| title=Long-term prognosis for patients with variant angina and influential factors. | journal=Circulation | year= 1988 | volume= 78 | issue= 1 | pages= 1-9 | pmid=3260150 | doi=10.1161/01.cir.78.1.1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3260150  }}</ref>
***Isosorbide mononitrate (Imdur) 60-240 mg PO qd
***[[Isosorbide mononitrate]] (Imdur) 60-240 mg PO qd
***Isosorbide dinitrate (Isordil) 20-40 mg PO tid
***[[Isosorbide dinitrate]] (Isordil) 20-40 mg PO tid
*'''Statins''':   
*'''Statins''':   
**May improve [[endothelial]] dysfunction and lower [[inflammation]].  A small, randomized control trial showed that fluvastatin 30 mg daily reduced rates of vasospasm.  [[Statins]] also provide benefits of [[LDL]] lowering and [[plaque]] stabilization.<ref name="pmid18452779">{{cite journal| author=Yasue H, Mizuno Y, Harada E, Itoh T, Nakagawa H, Nakayama M et al.| title=Effects of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, fluvastatin, on coronary spasm after withdrawal of calcium-channel blockers. | journal=J Am Coll Cardiol | year= 2008 | volume= 51 | issue= 18 | pages= 1742-8 | pmid=18452779 | doi=10.1016/j.jacc.2007.12.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18452779  }}</ref>
**May improve [[endothelial]] dysfunction and lower [[inflammation]].  A small, randomized control trial showed that [[fluvastatin]] 30 mg daily reduced rates of vasospasm.  [[Statins]] also provide benefits of [[LDL]] lowering and [[plaque]] stabilization.<ref name="pmid18452779">{{cite journal| author=Yasue H, Mizuno Y, Harada E, Itoh T, Nakagawa H, Nakayama M et al.| title=Effects of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, fluvastatin, on coronary spasm after withdrawal of calcium-channel blockers. | journal=J Am Coll Cardiol | year= 2008 | volume= 51 | issue= 18 | pages= 1742-8 | pmid=18452779 | doi=10.1016/j.jacc.2007.12.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18452779  }}</ref>
***Fluvastatin 30 mg PO qd
***Fluvastatin 30 mg PO qd
*'''Hormone replacement therapy''':   
*'''Hormone replacement therapy''':   
Line 1,932: Line 141:
====Medical Therapy====
====Medical Therapy====
*Risk factor modification (smoking cessation, [[lipid]] control) is recommended for all patients.
*Risk factor modification (smoking cessation, [[lipid]] control) is recommended for all patients.
*Begin [[pharmacologic]] therapy with oral [[calcium channel blockers]] (diltiazem, verapamil, nifedipine) and/or [[nitrates]].  If monotherapy is ineffective, begin combination therapy which is generally well tolerated (10% of patients may require 2 calcium channel blockers). If refractory or multi-vessel spasm is present, multiple CCBs are likely necessary, as these patients are at high risk for [[ventricular arrhythmias]]. Alpha blockers may also be useful if there is incomplete response to CCB and nitrates.  
*Begin [[pharmacologic]] therapy with oral [[calcium channel blockers]] ([[diltiazem]], [[verapamil]], [[nifedipine]]) and/or [[nitrates]].  If monotherapy is ineffective, begin combination therapy which is generally well tolerated (10% of patients may require 2 [[calcium channel blockers]]). If refractory or multi-vessel spasm is present, multiple CCBs are likely necessary, as these patients are at high risk for [[ventricular arrhythmias]]. Alpha blockers may also be useful if there is incomplete response to CCB and [[nitrates]].
*Due to their ability to improve endothelial function, [[statins]] should be considered for vasospasm.  
*Due to their ability to improve endothelial function, [[statins]] should be considered for [[vasospasm]].
*Certain medications should be avoided: nonselective [[beta blockers]], [[aspirin]], and sumatriptan can exacerbate vasospasm. [[Hormone replacement therapy]] ([[estrogen]]-[[progestin]]) have been associated with an increase in cardiac events (''HERS-II'' and ''WHI'' trials) and should also be avoided.
*Certain medications should be avoided: nonselective [[beta blockers]], [[aspirin]], and [[sumatriptan]] can exacerbate vasospasm. [[Hormone replacement therapy]] ([[estrogen]]-[[progestin]]) have been associated with an increase in cardiac events (''HERS-II'' and ''WHI'' trials) and should also be avoided.


====Percutaneous Intervention (PCI)====
====Percutaneous Intervention (PCI)====
*If [[vasospasm]] has a clearly definable area that is associated with coronary artery disease and refractory to medical therapy, stenting may be an effective strategy. However, stenting may simply propagate the spasm to a proximal or distal location in the vessel.
*If [[vasospasm]] has a clearly definable area that is associated with [[coronary artery disease]] and refractory to medical therapy, [[stenting]] may be an effective strategy. However, [[stenting]] may simply propagate the spasm to a proximal or [[distal]] location in the vessel.
*Following any [[PCI]], adjunctive medical therapy must be continued.
*Following any [[PCI]], adjunctive medical therapy must be continued.
*Resolution of symptoms, [[ECG]] changes, and [[angiographic]] [[vasospasm]] is usually apparent within one minute post-procedure.  
*Resolution of symptoms, [[ECG]] changes, and [[angiographic]] [[vasospasm]] is usually apparent within one minute post-procedure.  
*Refractory spasm occurring during [[PCI]] is likely secondary to [[dissection]], which requires stenting unless the artery is small and the patient is clinically stable.
*Refractory spasm occurring during [[PCI]] is likely secondary to [[dissection]], which requires stenting unless the artery is small and the patient is clinically stable.
*The role of revascularization in the setting of multivessel vasospasm is uncertain.
*The role of [[revascularization]] in the setting of multivessel vasospasm is uncertain.


====Surgery====
====Surgery====

Latest revision as of 18:23, 30 April 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2],Amandeep Singh M.D.[3] Roukoz A. Karam, M.D.[4] Synonyms and keywords: Variant angina; angina inversa; vasospastic angina

Overview

Vasospastic angina was previously referred to as Prinzmetal or variant angina. Vasospastic angina is a syndrome typically consisting of angina (cardiac chest pain) at rest that occurs in periodic cycles. Vasospastic angina is caused by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to atherosclerosis (buildup of fatty plaque and hardening of the arteries).

Historical Perspective

Printzmetal's angina was first described as a variant form in 1959 by the American cardiologist Dr. Myron Prinzmetal.[1]

It was first documented by coronary arteriography in 1973.[2]

Classification

Classification by Location

Coronary artery spasm can be classified according to the location of vasoconstriction:

Focal coronary spasm

Focal coronary spasm is limited to a localized segment of the coronary artery.

Multifocal coronary spasm

Multifocal coronary spasm involves several localized segments of the same coronary artery.

Multivessel coronary spasm

Multivessel coronary spasm involves several coronary arteries.[3][4]

Classification by Clinical Syndrome

Coronary artery vasospasm can be classified into either spontaneous or iatrogenic.

Spontaneous

Iatrogenic

Pathophysiology

  • The exact pathogenesis of coronary vasospasm is not well understood, but some causes and contributing factors are known.
  • A significant group of patients with variant angina have underlying obstructive coronary artery disease.[7]

Epidemiology and Demographics

  • Incidence or prevalence of Prinzmetal angina is still unknown.
  • Young patients with fewer cardiovascular risk factors (with the exception of smoking) are at a higher risk for coronary vasospasm, as are noncalcified lesions and eccentric plaques.
  • Some studies show that the Japanese population has an increased risk of developing vasospastic angina when compared with Caucasian populations.
  • The average age of presentation of vasospastic angina is around the fifth decade of life.[8]

Risk Factors

  • Smoking[9]
  • Genetic factors and insulin resistance
    • There is some evidence that genetic factors and insulin resistance are associated with vasospastic angina
  • Patients with vasospastic angina are often younger and exhibit fewer classic cardiovascular risk factors (except smoking).
  • Vasospastic angina may be associated with other vasospastic disorders, such as Raynaud's phenomenon and migraine headache or its treatment [54-56].
  • A history of drug abuse such as cocaine may be present.
  • Hyperventilation can precipitate attacks of vasospastic angina [57].

Differential diagnosis

Vasopastic angina must be differentiated from other diseases that cause chest pain, view chest pain differential diagnosis for more.

Natural History, Complications and Prognosis

  • There are no findings characteristic for vasospastic angina. However, during an episode, tachycardia, hypertension, diaphoresis, and a gallop rhythm may be present.
  • Bradycardia and hypotension can be observed if the sinus nodal, atrioventricular nodal, and right ventricular arteries are involved during proximal right coronary artery vasospasm.
  • If left untreated, 25% of patients with prinzmetal angina may progress to develop myocardial infarction and life threatening arrhythmias.[10][11]
  • Two-thirds of patients have concurrent atherosclerosis of a major coronary artery. This is often mild or not in proportion to the degree of symptoms.
  • Coronary vasospasm can lead to life-threatening arrhythmias, depending on the vessel that is involved.
  • Once detected, aggressive management of coronary vasospasm is necessary, as vasospasm can provoke fatal arrhythmias or myocardial infarction.[12]
  • Patients who have coronary artery disease in addition to coronary vasospasm have an overall worse prognosis.[13]
  • The prognosis of vasospastic angina depends on the extent of underlying coronary artery disease (CAD).

History and Symptoms

While the symptoms of chronic stable angina occur with exertion, the symptoms of Prinzmetal's angina typically occur at rest. The symptoms may occur reproducibly at certain times of the day or night. In the classic description, the symptoms often come on at night.

Characteristic pain features for vasospastic angina include:

  • Discomfort better describes the spasms than pain. Other common ways to describe the episodes: squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, a band-like sensation, knot in the center of the chest, lump in the throat, ache, and heavy weight on chest.
  • Each episode is typically gradual in onset and offset.
  • There is no change in the quality of pain with respiration or position.
  • The patient may have some difficulty in describing the location of the pain, although the substernal location is common. Radiation to the neck, throat, lower jaw, teeth, upper extremity, or shoulder is common.
  • During each episode, symptoms of nausea, sweating, dizziness, dyspnea, and palpitations may be present.

Diagnosis

  • Physicians should suspect vasospasm if ST segment elevation is detected in patients experiencing angina, and if the ECG completely returns to baseline upon resolution of symptoms.
    • These changes are usually transient (less than 15 minutes) and may occur in multiple leads of a 12-lead ECG.
  • Patients who develop cardiac chest pain are generally treated empirically as an "acute coronary syndrome" patient, and are generally evaluated with serial testing of cardiac enzymes such as creatine kinase isoenzymes or troponin I or T. These may in some cases be abnormal or positive, as coronary spasm can lead to myocardial necrosis in severe cases.
  • The gold standard test is coronary angiography including the administration of provocative agents, such as acetylcholine or ergonovine, via the intracoronary route. The definitive diagnosis of coronary vasospasm is made angiographically by demonstration of reduction of luminal diameter in a discrete segment of the vessel, which is proven to be reversible. Reversibility may be demonstrated by previous or subsequent enlargement of luminal diameter, often after the administration of intracoronary vasodilators.
  • It should be noted that two-thirds of patients with Prinzmetal's angina have concurrent atherosclerosis of a major coronary artery, but the extent of the atherosclerosis is generally mild, and the symptoms are out of proportion to the extent of disease. Depending on the local protocol, provocative testing may utilize either ergonovine, methylergonovine or acetylcholine. Exaggerated spasm is diagnostic of Prinzmetal's angina. Care should be taken to have nitrates and calcium channel agents readily available to reverse the spasm.

Electrocardiogram

Prinzmetal's angina is associated with transmural injury and ST segment elevation rather than ST segment depression.

The most important ECG change during a focal proximal coronary spasm is in around 50% of cases the appearance of peaked and symmetrical T wave that is followed, if the spasm persist, by progressive ST-segment elevation that last for a few minutes, and later progressively resolve.[14]

The most frequent ECG changes associated with ST-segment elevation are:

  • Increased height of the R wave
  • Coincident S-wave diminution
  • Upsloping TQ in many cases
  • Alternans of the elevated ST-segment
  • Negative T wave deepness
    • In 20% of cases.

Treatment

Prinzmetal angina typically responds to nitrates and calcium channel blockers. Patients with multivessel spasm, refractory spasm, spasm that results in sudden death may benefit from dual calcium channel blocker therapy.

  • Calcium channel blockers:
    • Generally, well tolerated and can aid with hypertension control.[15]
    • A combination of dihyropyridine and non-dihydropyridine calcium channel blockers should be used in patients with refractory coronary vasospasm, particularly if it has resulted in ventricular arrhythmia.
    • Multiple calcium channel blockers may be required in patients with refractory or multi-vessel spasm.
    • A patient who has suffered ventricular tachycardia or ventricular fibrillation due to spontaneous vasospasm (not due to acute infarction) should also likely undergo ICD placement.
  • Long-acting nitrates:
  • Statins:
  • Hormone replacement therapy:
    • This remains controversial, particularly due to the risk of concern of increased cardiac events.
  • Smoking cessation:
  • Percutaneous coronary intervention:
    • While resolution occurs following PTCA/stenting in some cases, spasm can propagate to a new location, proximal or distal to the stented site.[19]
    • PCI is not commonly indicated for patients with focal spasm and minimal obstructive disease. However, it may be helpful if significant obstructive coronary disease is present and thought to be a potential trigger for focal spasm.
  • ICD placement:
  • Surgical autonomic denervation/plexectomy:
    • Can be useful in cases that are refractory to medical therapy or percutaneous intervention. It's reserved only for the most refractory cases.

Making a Selection

  • Treatment of chronic vasospasm should be performed in this order (step-wise fashion): medical therapy, percutaneous intervention, and then, surgery.

Medical Therapy

Percutaneous Intervention (PCI)

  • If vasospasm has a clearly definable area that is associated with coronary artery disease and refractory to medical therapy, stenting may be an effective strategy. However, stenting may simply propagate the spasm to a proximal or distal location in the vessel.
  • Following any PCI, adjunctive medical therapy must be continued.
  • Resolution of symptoms, ECG changes, and angiographic vasospasm is usually apparent within one minute post-procedure.
  • Refractory spasm occurring during PCI is likely secondary to dissection, which requires stenting unless the artery is small and the patient is clinically stable.
  • The role of revascularization in the setting of multivessel vasospasm is uncertain.

Surgery

  • In the rare circumstance that a patient is refractory to pharmacologic and percutaneous therapy, surgical denervation and plexectomy have been effective.

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [20]

Recommendations for Prizmental's angina

Class I
"1.CCBs alone or in combination with long-acting nitrates are useful to treat and reduce the frequency of vasospastic angina.(Level of Evidence: B)"
"2.Treatment with HMG-CoA reductase inhibitor, cessation of tobacco use, and additional atherosclerosis risk factor modification and are useful in patients with vasospastic angina. (Level of Evidence: B)"
"3.Coronary angiography (invasive or noninvasive) is recommended in patients with episodic chest pain accompanied by transient ST-elevation to rule out severe obstructive CAD. (Level of Evidence: C)"
Class IIb
"1. Provocative testing during invasive coronary angiography†† may be considered in patients with suspected vasospastic angina when clinical criteria and noninvasive testing fail to establish the diagnosis (Level of Evidence: B)"

ESC Guidelines for Diagnostic Tests in Suspected Vasospastic Angina (DO NOT EDIT)[21]

Class I
"1. ECG during angina if possible. (Level of Evidence: B)"
"2. Coronary arteriography in patients with characteristic episodic chest pain and ST-segment changes that resolve with nitrates and/or calcium channel blockers to determine the extent of underlying coronary disease. (Level of Evidence: B)"
Class IIa
"1. Intracoronary provocative testing to identify coronary spasm in patients with normal findings or nonobstructive lesions on coronary arteriography and the clinical picture of coronary spasm. (Level of Evidence: B)"
"2. Ambulatory ST Segment Monitoring to identify ST-deviation. (Level of Evidence: C)"

ESC Guidelines for Pharmacological Therapy of Vasospastic Angina (DO NOT EDIT)[21]

Class I
"1. Treatment with calcium channel blocker and if necessary nitrates in patients whose coronary arteriogram is normal or shows only non-obstructive lesions. (Level of Evidence: B)"

References

  1. ↑ Prinzmetal M, Kennamer R, Merliss R. of angina pectoris. Am J Med 1959;27:375-88. PMID 14434946.
  2. ↑ Oliva PB, Potts DE, Pluss RG (1973). "Coronary arterial spasm in Prinzmetal angina. Documentation by coronary arteriography". N Engl J Med. 288 (15): 745–51. doi:10.1056/NEJM197304122881501. PMID 4688712.
  3. ↑ Ahooja V, Thatai D (2007). "Multivessel coronary vasospasm mimicking triple-vessel obstructive coronary artery disease". J Invasive Cardiol. 19 (7): E178–81. PMID 17620681. Unknown parameter |month= ignored (help)
  4. ↑ Miwa K, Ishii K, Makita T, Okuda N (2004). "Diagnosis of multivessel coronary vasospasm by detecting postischemic regional left ventricular delayed relaxation on echocardiography using color kinesis". Circ. J. 68 (5): 483–7. PMID 15118293. Unknown parameter |month= ignored (help)
  5. ↑ Lanza GA, Careri G, Crea F (2011). "Mechanisms of coronary artery spasm". Circulation. 124 (16): 1774–82. doi:10.1161/CIRCULATIONAHA.111.037283. PMID 22007100.
  6. ↑ Mahemuti A, Abudureheman K, Schiele F, Ecarnot F, Abudureyimu S, Tang B; et al. (2014). "Association between inflammatory markers, hemostatic markers, and traditional risk factors on coronary artery spasm in patients with normal coronary angiography". J Interv Cardiol. 27 (1): 29–35. doi:10.1111/joic.12086. PMID 24345233.
  7. ↑ Maseri A, Severi S, Nes MD, L'Abbate A, Chierchia S, Marzilli M et al. (1978) "Variant" angina: one aspect of a continuous spectrum of vasospastic myocardial ischemia. Pathogenetic mechanisms, estimated incidence and clinical and coronary arteriographic findings in 138 patients. Am J Cardiol 42 (6):1019-35. PMID: 727129
  8. ↑ Kim HL, Lee SH, Kim J, Kim HJ, Lim WH, Seo JB; et al. (2016). "Incidence and Risk Factors Associated With Hospitalization for Variant Angina in Korea". Medicine (Baltimore). 95 (13): e3237. doi:10.1097/MD.0000000000003237. PMC 4998556. PMID 27043695.
  9. ↑ Takaoka K, Yoshimura M, Ogawa H, Kugiyama K, Nakayama M, Shimasaki Y; et al. (2000). "Comparison of the risk factors for coronary artery spasm with those for organic stenosis in a Japanese population: role of cigarette smoking". Int J Cardiol. 72 (2): 121–6. doi:10.1016/s0167-5273(99)00172-2. PMID 10646952.
  10. ↑ Kishida H, Tada Y, Tetsuoh Y, Yamazaki Y, Saito T, Fukuma N; et al. (1991). "A new strategy for the reduction of acute myocardial infarction in variant angina". Am Heart J. 122 (6): 1554–61. doi:10.1016/0002-8703(91)90271-i. PMID 1835559.
  11. ↑ Myerburg RJ, Kessler KM, Mallon SM, Cox MM, deMarchena E, Interian A; et al. (1992). "Life-threatening ventricular arrhythmias in patients with silent myocardial ischemia due to coronary-artery spasm". N Engl J Med. 326 (22): 1451–5. doi:10.1056/NEJM199205283262202. PMID 1574091.
  12. ↑ Kishida H, Tada Y, Tetsuoh Y, Yamazaki Y, Saito T, Fukuma N; et al. (1991). "A new strategy for the reduction of acute myocardial infarction in variant angina". Am Heart J. 122 (6): 1554–61. doi:10.1016/0002-8703(91)90271-i. PMID 1835559.
  13. ↑ Bory M, Pierron F, Panagides D, Bonnet JL, Yvorra S, Desfossez L (1996). "Coronary artery spasm in patients with normal or near normal coronary arteries. Long-term follow-up of 277 patients". Eur Heart J. 17 (7): 1015–21. doi:10.1093/oxfordjournals.eurheartj.a014996. PMID 8809518.
  14. ↑ de Luna AB, Cygankiewicz I, Baranchuk A, Fiol M, Birnbaum Y, Nikus K; et al. (2014). "Prinzmetal angina: ECG changes and clinical considerations: a consensus paper". Ann Noninvasive Electrocardiol. 19 (5): 442–53. doi:10.1111/anec.12194. PMID 25262663.
  15. ↑ Yasue H, Takizawa A, Nagao M, Nishida S, Horie M, Kubota J; et al. (1988). "Long-term prognosis for patients with variant angina and influential factors". Circulation. 78 (1): 1–9. doi:10.1161/01.cir.78.1.1. PMID 3260150.
  16. ↑ Yasue H, Takizawa A, Nagao M, Nishida S, Horie M, Kubota J; et al. (1988). "Long-term prognosis for patients with variant angina and influential factors". Circulation. 78 (1): 1–9. doi:10.1161/01.cir.78.1.1. PMID 3260150.
  17. ↑ Yasue H, Mizuno Y, Harada E, Itoh T, Nakagawa H, Nakayama M; et al. (2008). "Effects of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, fluvastatin, on coronary spasm after withdrawal of calcium-channel blockers". J Am Coll Cardiol. 51 (18): 1742–8. doi:10.1016/j.jacc.2007.12.049. PMID 18452779.
  18. ↑ Miwa K, Fujita M, Miyagi Y (1994). "Beneficial effects of smoking cessation on the short-term prognosis for variant angina--validation of the smoking status by urinary cotinine measurements". Int J Cardiol. 44 (2): 151–6. doi:10.1016/0167-5273(94)90019-1. PMID 8045660.
  19. ↑ Corcos T, David PR, Bourassa MG, Val PG, Robert J, Mata LA; et al. (1985). "Percutaneous transluminal coronary angioplasty for the treatment of variant angina". J Am Coll Cardiol. 5 (5): 1046–54. doi:10.1016/s0735-1097(85)80004-8. PMID 3157733.
  20. ↑ Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
  21. ↑ 21.0 21.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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