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Clinical Case: Chest Pain

(Aortic Dissection, ACS-AMI, UA)

Course: Introductions to Clinical Medicine


Prepared/Modified by Dr. Tetiana
Hliebova
Winter 2018
Intended Learning Objectives
by the end of this lecture you will be able to:

1. Definition, etiology and pathogenesis of Aortic Dissection


and Acute Coronary Syndrome.
2. Types of Angina and Myocardial Infarction.
3. Morphology, clinical presentation, diagnostic approaches
and treatment of:
• Angina Pectoris: Stable, Unstable
• Myocardial Infarction
• Sudden Cardiac Death (SCD)
• S+ T
• ACS:
• 1. angina: SA and UA
• UA: STEMI, NSTEMI, SCD
Aortic Dissection
• The spread of blood into an intimal tear in the wall of
the aorta causing a second lumen to form Introduction
• caused by elastic tissue degradation
• blood enters space between intima and tunica
media
• blood can pass proximally or distally

• Risk factors
• hypertension
• due to damage to endothelial cell layer
predisposing to tear
• trauma
• coarctation of the aorta (narrowing of aorta) 
increasing pressure*
• syphilis
• due to vasculitis and occlusion of vasa
vasorum (vessel of vessels)
• Ehlers-Danlos syndrome type 3
• Marfan's Syndrome (due to cystic medial
degeneration resulting from defect in fibrillin-1)
• pregnancy
• due to ↑ plasma volume
• copper deficiency
• due to weak collagen without copper-
dependent enzymatic cross-linking
Symptoms:
• classical presentation:
• acute onset of severe tearing anterior
chest pain radiating to the back  aortic
Presentation
dissection*
• asymmetric upper extremity blood
pressures – when measured BP
difference within 10-20*
• due to compression of subclavian
artery unilaterally
•in severe cases:
• syncope
• decreased pulse
• shock
• Where rupture? rupture into pericardial
sac***, pleural cavity, or peritoneal
cavity  hence no space for heart to
contract*** 
• cardiac tamponade*** (completely
filled with blood) is the most
common cause of death****
Physical Exam:
• asymmetric upper extremity pulses
• diastolic murmur secondary to aortic
regurgitation (dilation of the aorta stretches
the aortic ring with widening of the aortic root)
Evaluation
ACS
Predisposition to atherosclerosis and MI

Injury to endothelial cell, accumulation of platelets and clots


Positive stress – to unstable
Approaching the Patient
with “Chest Pain”

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