Differentials on the basis of Etiology
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Disease
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Clinical manifestations
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Diagnosis
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Symptoms
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Risk factors
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Physical exam
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Lab Findings
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EKG
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Imaging
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Gold standard
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Onset
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Duration
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Quality of Pain
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Cough
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Fever
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Dyspnea
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Weight loss
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Associated Features
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Stable Angina[1]
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Sudden (acute)
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2-10 minutes
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- Heaviness/pressure/ tightness/squeezing/ burning (Levine's sign)
- Retrosternal or left sided chest pain
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-
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-
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+/-
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-
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- Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
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|
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- Exercise EKG: ST-segment depression
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- Exercise Stress Testing: Decreased myocardial perfusion
- Transthoracic echocardiography: Ejection fraction <50 percent
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|
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Unstable Angina[2][3][4]
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Acute
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10-20 minutes
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- Same as stable angina but often more severe
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-
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-
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+
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-
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- Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
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|
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- ST-depression
- New T wave inversions
- Transient ST-elevation
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- Echocardiography: Ejection fraction <50 percent
- Exercise Stress Testing: Decreased myocardial perfusion
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- Invasive coronary angiography
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|
Myocardial Infarction[5][6][7][8]
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Acute
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Commonly > 20 minutes
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- Same as stable angina but often more severe
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-
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-
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+
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-
|
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- Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
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|
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- ST elevation MI (STEMI)
- Non-ST elevation MI (NSTEMI) or Non Q wave
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- Echocardiography: ↓ EF
- CCTA: Coronory artery stenosis
- CMRI: Coronory vessels stenosis
- MPI on SPECT or PET scanning: Decreased myocardial perfusion.
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Cardiac
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Vasospastic/ Prinzmetal/ Variant Angina[9][10]
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Gradual in onset and offset
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Episodic, gradual in onset and offset.
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- 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
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-
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-
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+
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-
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- Nausea, sweating, dizziness, dyspnea, and palpitations
- Associated with other vasospastic disorders, such as Raynaud's phenomenon and migraine headache
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- 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
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- Tachycardia, hypertension, diaphoresis, and a gallop rhythm
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- Urine drug screen may be positive for cocaine or other drugs
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- 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
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- 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
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Aortic Dissection[11][12]
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Sudden severe progressive pain (common) or chronic (rare)
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Variable
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- Tearing, ripping sensation, knife like
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-
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-
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+
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-
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- 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)
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|
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- Nonspecific ST and T wave changes
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- 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
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- CT angiography
- Digital subtraction aortography (if high suspicion)
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Pericarditis[13][14][15]
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Acute or subacute
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May last for hours to days
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- Sharp & localized retrosternal pain
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+
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+
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+
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-
|
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- HIV
- TB
- Immunosuppression
- Acute trauma
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|
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- EKG changes (typically widespread ST segment elevation or PR depressions)
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- Chest x-ray typically normal
- Echocardiogram: normal or pericardial effusion
- CT scan: Noncalcified pericardial thickening with pericardial effusion
- CMR: inflamed pericardium and myocarditis
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- Pericardiocentesis
- Pericardial biopsy
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