complaints,such as fatigue, myalgias, nausea, vomiting, diarrhea, and fever,
are usually the earliest symptoms and signs of myocarditis. Tachycardia is
common and can be disproportionate to the patient’s temperature (ie,
HR faster than what is expected).This may be the only clue that something
more serious than a simple viral illness exists. Approximately 12% of patients
also complain of chest pain. Cardiac enzymes may be elevated and the CBC
and erythrocyte sedimentation rate (ESR) are nonspecific.
(a)Streptococcus viridansis a common cause of acute bacterial endo-
carditis, an infection of a cardiac valve. (b)Staphylococcus aureusis not
known to cause myocarditis. (d)Myocarditis can masquerade as an acute
MI because patients with either may have severe chest pain, ECG changes,
elevated cardiac enzymes, and heart failure. Patients with myocarditis are
usually young and have few risk factors for CAD. (e)Cocaine use can cause
chest pain and tachycardia. It does not lead to flu-like symptoms.
33.The answer is b.(Selwyn, 2005.)The patient’s clinical presentation is
consistent with Prinzmetal or variant angina.This condition is caused by
focalcoronary artery vasospasm. Itoccurs at rest and exhibits a
circadian pattern,with most episodes occurring in the early hours of the
morning. The pain commonly is severe. Distinguishing unstable angina
related to coronary atherosclerosis from variant angina may be difficult and
requires special investigations, including coronary angiography. Patients
may also exhibit ST elevations on their ECGs. Nitrates and CCBs are the
mainstays of medical therapy for variant angina. Nitroglycerin effectively
treats episodes of angina and myocardial ischemia within minutes of
administration, and the long-acting nitrate preparations reduce the fre-
quency of recurrent events. CCBs effectively prevent coronary vasospasm
and variant angina, and they should be administered in lieu of β-blockers.
(a)Aspirin is an antiplatelet agent that helps reduce progression of
plaque formation in the coronary arteries. Aspirin won’t treat the vasospasm
that is responsible for variant angina. (c)β-Blockers can be beneficial in
patients with fixed coronary artery stenosis and exertional angina. However,
for variant angina, nonselective β-blockers may be detrimental in some
patients because blockade of the β-receptors, which mediate vasodilation,
allows unopposed β-receptor–mediated coronary vasoconstriction to occur,
thus possibly causing an actual worsening of symptoms (d)H 2 -blockers are
used to treat acid reflux symptoms. (e)The etiology of the patient’s symptoms
will not be relieved by an antidepressant.
Chest Pain and Cardiac Dysrhythmias Answers 41