Clinical features of Angina Pectoris and Myocardial Infarction

Clinical features of Angina Pectoris and Myocardial Infarction

Cardiac Pain or Angina Pectoris ( reversible loss of blood supply to the heart muscle) is retrosternal, vague, poorly localized, heavy, compressive, squeezy feeling. It rarely lasts less than 1 minute or more than 20 minutes, unless it is a heart attack. Patients get prompt relief in less than 5 minutes on cessation of all activities or use of sublingual nitrates. Angina pain can also be in the left shoulder, left arm, neck or the jaws.
Pain of a Myocardial Infarction ( total sudden blockage of an artery supplying blood to the heart muscle) would be similar to this but more severe and can last longer, will not be relieved by rest or sublingual nitrate and associated with palpitation, perspiration, nausea/vomiting, dizziness, blackout or even collapse.
Pain that is unlikely to be of cardiac origin is typically well localized, sharp, pricky, lancinating type sometimes lasting less than 15 seconds. It can be aching type too but mostly will be aggravated on deep inspiration and coughing. Patient will be able to localize it with the tip of her finger.
Pain that is localized just below left nipple is almost NEVER of cardiac origin.

Common causes of chest pain in young females

1. Valvular Heart Disease

Mitral Prolapse: This is a common and benign condition. Leaflets of the Mitral valve are long, bulky and redundant. They prolapse into the left atrium during systole. It is unknown how this causes chest pain. Suffice to say that the pain occurs at rest, is sharp, non- radiating and prolonged in duration.
Rheumatic Valve Disease: Mitral stenosis is a common rheumatic valve condition in females and can cause chest pain and dyspnea. The patient will have associated cough, expectoration, there would be a low pitched rumbling diastolic murmur which will clinch the diagnosis. A 2D echocardiography will be confirmatory.

2. Anxiety/Depression

There are a lot of personal/social causes for a young female to get into a vicious cycle of anxiety causing various physical symptoms, and those symptoms in turn causing more anxiety. Depression also causes ?somatization? and produces various symptoms, chest pain being one of them. This chest pain can take any form; it can even mimic Anginal pain accurately. One needs to rule out organic causes before stamping the diagnosis of anxiety/depression.

3. Neuromusculoskeletal

The pain is very well localized, tender on touch, aggravated on deep inspiration, and not aggravated on exertion. Underlying cause can be pinpointed by suitable investigations like X ray of cervical spine, chest (thoracic outlet syndrome) etc. Pain of herpes Zoster sometimes defies diagnosis until the rash develops.

4. Gastrointestinal

Esophageal reflux is one of the most common causes of retrosternal pain. The pain is mostly burning in nature, occurs more often in reclining posture, and is relieved by assuming upright position. It is more frequent after an oily, heavy meal. Esophageal spasm is a variety of the same disease. Sometimes peptic ulcer disease can also cause pain in lower chest.

5. Pulmonary

Pulmonary cause of chest pain in young female could be a pulmonary embolism/infarct caused by deep vein thromboembolism resulting from oral contraception usage. The pain is acute, severe and patient generally is in a critical condition.
Pneumonia can also cause chest pain if there is pleural involvement with it, which usually is the case.
Pneumothorax, which is rupture of a lung alveolus into the pleural cavity will cause sudden acute filling up of air pressure in pleura and will cause severe acute chest pain if it is Tension Pneumothorax and moderate dull aching pain if it is simple Pneumothorax.

6. Pleurisy

Tubercular involvement of the pleura is called pleurisy. The pain is sharp stab like, occurring on slightest act of breathing. Associated features are low grade fever, cough, and malaise, loss of appetite and loss of weight.
Chest pain in a young female has lots of reasons as we have seen. Most of the time they are not of cardiac origin. A thorough clinical examination, appropriate investigations, and reassurance will go a long way in resolving this issue.
Dr. Apurva Madia

Statins: Symptom Masking and Medicine Stacking

Western medicine has migrated toward specialization and prescriptions drugs—this leads us to missing the forest for the trees.  Women’s medicine is full of “symptom masking and medicine stacking.”  Statin use to lower cholesterol is just one more example of this less-than-ideal approach to women’s healthcare.
The question needs to be “what is the root cause of a particular woman’s elevated cholesterol?”  What are her other symptoms?  Does she have fatigue, easy weight gain, frequent infections, food intolerances, or feel cold all the time?  Low thyroid function and chronic stress could be the underlying causes.  Does she struggle with cyclical headaches, depression, irritability, insomnia, and painful periods?  An imbalance between estrogen and progesterone in the last half of her cycle could be the culprit.  Most women are not aware of how estrogen, progesterone, and thyroid function have direct effects on how the liver processes cholesterol.
Educating women on how hormone balance and thyroid function affect whole body health is important so that they can be their own advocates in the doctor’s office and can implement healthy lifestyle changes to promote better hormone balance.  We need to shift the tide in women’s healthcare towards a more positive and holistic approach—statin use is just one manifestation of an underlying problem in women’s medicine today.

Laurie Heap, MD has been speaking with women in small group settings about hormonal health, happiness, stress management, and relationships for the last 15 years. To learn more, visit RUhealthyRUhappyMD.com, her Facebook page, or follow her on twitter at @LaurieHeap.

 source:

• Alternative Medicine

Prince's charity lobbied government to water down homeopathy criticism

Draft guidance stated: 'There is no good quality evidence to show that homeopathy is more successful than placebo.' Photograph: Peter Macdiarmid/Getty Images

Draft guidance for the website NHS Choices warning that there is no evidence that homeopathy works was suppressed by officials following lobbying by a charity set up by the Prince of Wales.
Homeopathy, which involves the use of remedies so heavily diluted with water that they no longer contain any active substance, is "rubbish", said chief medical officer Sally Davies in January to the House of Commons science and technology committee. She added that she was "perpetually surprised" that homeopathy was available in some places on the NHS.
But the government's NHS Choices website, which is intended to offer evidence-based information and advice to the public on treatments, does not reflect her view. A draft page that spelled out the scientific implausibility of homeopathic remedies was neutered by Department of Health officials. It is now uncritical, with just links to reports on the lack of evidence.
Lobbying by opponents, and the response from DH officials who did not want to take on Prince Charles's now defunct Foundation for Integrated Medicine and other supporters of homeopathy, is revealed in correspondence from the department discussing the new guidance. It was released under the Freedom of Information Act to Prof David Colquhoun of University College London, a Fellow of the Royal Society and prominent science blogger.
There is no evidence that Prince Charles was involved personally in the lobbying.
The editor of the draft advice, David Mattin – who has now left NHS Choices – said in a statement to Colquhoun, published on his blog, that the DH had failed patients. "In causing NHS Choices to publish content that is less than completely frank about the evidence on homeopathy, the DH have compromised the editorial standards of a website that they themselves established and that they fund. They have sold out the NHS Choices editorial team who work tirelessly to fulfil their remit. And, most seriously, they have failed the general public, by putting special interests, politics and the path of least resistance (as they saw it) before the truth about health and healthcare."
NHS Choices has offered information on homeopathy since at least 2007, but it has been heavily criticised for its failure to state that there is no proof that homeopathy has anything other than a placebo effect on patients.
The page was taken down early in 2011, pending what a statement on the site said would be "a review by the Department of Health policy team responsible for complementary and alternative medicines". But critics were disappointed by the page that went up in October 2012, which still does not raise any issues about effectiveness.
What had been happening behind the scenes in the couple of years before the disappearance of the page and during its absence is revealed in the correspondence between NHS Choices, department officials and the foundation.
Mattin's original draft said: "There is no good quality clinical evidence to show that homeopathy is more successful than placebo in the treatment of any condition … Furthermore, if the principles of homeopathy were true it would violate all the existing theories of science that we make use of today; not just our theory of medicine, but also chemistry, biology and physics."
But the homeopathy lobby was in close contact with the department. In December 2009, an official from the department wrote to NHS Choices asking to see "the articles you're writing" and announcing that he had called "an exploratory meeting with the Prince's Foundation for Integrated Health and the Complementary and Natural Healthcare Council … so that we could start to piece this particular jigsaw together."
On 29 December, a letter was sent from the foundation to the department expressing strong feelings about a draft document. "It was just a bit horrifying as it was not only anti-complementary medicine and patients who might use it but clearly drawn up by someone who had no knowledge of this field and was largely factually incorrect," said the letter.
In January, further emails from the foundation strongly opposed the involvement of the Exeter-based professor of complementary medicine, Edzard Ernst – now retired and a strong critic of homeopathy – as an adviser.
The documents reveal subsequent changes to Mattin's draft by DH officials. The draft stated: "A House of Commons science and technology report said that homeopathic remedies perform no better than placebos and that the principles on which homeopathy is based are 'scientifically implausible'."
That critique disappeared. A comment in the margin, apparently from somebody in the department, says: "Can we remove this statement? This report is really quite contentious and we may well be subject to quite a lot of challenge from the homeopathic community if published."
A further intervention by the DH also removed the statement that "a 2010 science and technology committee report said that scientific tests had shown that homeopathic treatments don't work."
Mattin says officials were more worried about potential political fallout from homeopathy supporters than about publishing evidence-based information. He says his draft was delayed and then suppressed.
"My strong impression was of DH civil servants who lacked the courage and, frankly, the energy to stand up to the criticism from special interest groups that they anticipated would arise because of the article; and that indeed did arise when a draft of the article and other draft content on complementary and alternative medicines fell into the hands of the Prince's Foundation and other [complementary and alternative medicine] groups."
The department did not respond to a request to comment. The Prince's Foundation for Integrated Health was closed in 2010 following allegations of fraud and money-laundering that led to the conviction of a charity official for stealing more than £250,000.


source:
http://www.guardian.co.uk/lifeandstyle/2013/feb/13/prince-charity-lobbied-government-homeopathy