Cardiology for the primary care Physician PDF
Preview Cardiology for the primary care Physician
CARDIOLOGY for the primary care PHY8ICIAN 3rd edition Edited by: Joseph Alpert ~. Professor and Chairman Department of Medicine University of Arizona Health Sciences Center Tucson, Arizona with 75 contributors Developed by Current Medicine, Inc., Philadelphia Current Medicine, Inc. DIRECTOR OF PRODUCT DEVELOPMENT ........................... Charles Field BOOKS SUPERVISOR ........................................... Fran Klass DEVELOPMENTAL EDITOR ..................................... Lisa M. Janda EDITORIAL ASSISTANT. .................................. Annmarie D'Ortona ART AND ILLUSTRATION DIRECTOR .............................. Wendy Vetter COVER DESIGN .................................... Christine Keller-Quirk LAYOUT ........................... Christine Keller-Quirk and Jennifer Knight ILLUSTRATOR ...... .................. . Wiesia Langenfeld and Maureen Looney PRODUCTION MANAGER ..................................... Lori Holland ASSISTANT PRODUCTION MANAGER ............................. Simon Dickey INDEXER ....................................... . .... Dorothy Hoffman Cardiology for the primary care physician / edited by Joseph S. Alpert, with 75 Contributors. -3rd ed. p.; cm. Includes bibliographical references and index. ISBN 978-1-4615-6603-8 ISBN 978-1-4615-6601-4 (eBook) DOI 10.1007/978-1-4615-6601-4 1. Cardiology. 2. Primary care (Medicine) 3. Heart-Diseases. 1. Alpert, Joseph S. [DNLM: 1. Heart Diseases. 2. Primary Health Care. WG 210 C2677 2000] RC667 .C3834 2000 616.1'2-dc21 00-034621 Library of Congress Cataloging-in-Publication Data For more information please call I-H00-427-1796 or email [email protected] www.current-science-group.com 10987654321 ISBN 978-1-4615-6603-8 © Copyright 2001 by Current Medicine, Inc., 400 Market Street, Suite 700, Philadelphia, PA 19106. All rights Softcover reprint of the hardcover 3rd edition 2001 reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of the publisher. Although every effort has been made to ensure that drug doses and other information are presented accurately in this publication, the ultimate responsibility rests with the prescribing physician. Neither the publishers nor the author can be held responsible for errors or for any consequences arising from the use of the information contained therein. Any product mentioned in this publication should be used in accordance with the prescribing information prepared by the manufacturers. No claims or endorsements are made for any drug or compound at present under clinical investigation. II Contributors JOSEPH S. ALPERT, MD MELVIN D. CHEITLIN, MD, MACC MICHAEL A. FIFER, MD Professor of Medicine Emeritus Professor of Medicine Associate Professor University of Arizona Department of Medicine Department of Medicine Head, Department of Medicine University of California at San Francisco Harvard Medical School University of Arizona Health Sciences San Francisco, California Director, Coronary Care Unit Center Massachusetts General Hospital Tucson, Arizona JOHN S. CHILD, MD, FACC Boston, Massachusetts Co-Chief for Clinical Cardiology JACK E. ANSELL, MD Adult and Congenital Heart Disease Center EDWARD A. FISHER, MD Professor and Vice Chair UCLA School of Medicine Clinical Associate Professor Department of Medicine Department of Medicine Department of Medicine Boston University School of Medicine Division of Cardiology Assistant Director of Echocardiography Boston, Massachusetts Los Angeles, California Mt. Sinai Hospital New York, New York MOHAMMAD ASIF, MD JULIUS J. CHOSY, BA, MD Assistant Professor of Medicine Professor Emeritus MARC FISHER, MD Department of CardiologylMedicine Department of Medicine Professor of Neurology University of Medicine and Dentistry of University of Wisconsin University of Massachusetts Medical School New Jersey Madison, Wisconsin Worcester, Massachusetts Attending Cardiologist PETER F. COHN, MD GERALD F. FLETCHER, MD Newark Beth Israel Hospital Professor of Medicine Professor of Medicine Newark, New Jersey Department of Medicine Mayo Medical School OMER A. BAJWA, MD Chief, Division of Cardiology Senior Associate Consultant Resident State University of New York Health Mayo Clinic Department ofInternal Medicine Sciences Center Jacksonville, Florida University of South Dakota Medical School Stony Brook, New York BARRY A. FRANKLIN, BS, MS, PHD Sioux Falls, South Dakota DEBORAH M. DEMARCO, MD Professor RICHARD C. BECKER, MD Associate Professor Department of Physiology Professor of Medicine Department of Medicine/Rheumatology Wayne State University University of Massachusetts Associate Vice Chair, Postgraduate Detroit, Michigan Director, Cardiac Care Unit Education Director, Cardiac Rehabilitation and University of Massachusetts Memorial University of Massachusetts Exercise Laboratories Medical Center Worcester, Massachusetts William Beaumont Hospital Worcester, Massachusetts Royal Oak, Michigan VINCENT DEQUATTRO, MD CHARLES M. BLATT, MD Professor of Medicine DAVID F. GIANSIRACUSA, MD Assistant Clinical Professor of Medicine University of Southern California School of Professor Department of Medicine Medicine Department of Medicine Harvard Medical School Director, Hypertension Diagnostic Lab University of Massachusetts Medical School Associate Physician Los Angeles, California Vice Chair, Medicine-Undergraduate Brigham and Women's Hospital Education and Faculty Affairs RICHARD B. DEVEREUX, MD Boston, Massachusetts Staff Rheumatologist Professor of Medicine University of Massachusetts Medical Center BRAD S. BURLEW, MD Cornell University Medical College Worcester, Massachusetts Professor of Medicine Director, Echocardiography Laboratory University of Tennessee The New York Hospital MARTIN E. GOLDMAN, MD Chief of Cardiology New York, New York Dr. Arthur and Hilda Master Professor of Regional Medical Center Medicine/Cardiology GORDON A. EWY, MD Memphis, Tennessee Mt. Sinai School of Medicine Professor Director, Echocardiography SEEMANT CHATURVEDI, MD Department of Medicine Mt. Sinai Medical Center Associate Professor of Neurology University of Ariwna New York, New York Wayne State University Chief of Cardiology Co-Director, Harper Hospital Stroke Unit University of Arizona Health Sciences Detroit, Michigan Center Tucson, Arizona ttl THOMAS B. GRABOYS, MO RUSSELL O. HULL, MBBS, MSc ERIC L. MICHELSON, MO Associate Clinical Professor of Medicine Professor of Medicine Adjunct Professor Department of Medicine University of Calgary Department of Medicine Harvard Medical School Director Thrombosis Research Unit Thomas Jefferson University Associate Physician Calgary, Alberta, Canada Philadelphia, Pennsylvania Brigham and Women's Hospital Director, Cardiovascular Therapy Area MICHAEL H. HUMPHREYS, MO Boston, Massachusetts AstraZeneca Professor of Medicine Wayne, Pennsylvania HONGSHENG M. Guo, MO University of California San Francisco Resident Chief, Division of Nephrology CHARLES K. MOORE, MO Department of Medicine San Francisco General Hospital Assistant Professor of Medicine University of South Dakota Medical School San Francisco, California Department of Medicine Sioux Falls, South Dakota University of Mississippi Medical Center STEVEN B. JOHNSON, MO, FACS Jackson, Mississippi LESLIE R. HARROLD, MO, MPH Associate Professor of Surgery Assistant Professor of Medicine University of Arizona MAHER NAHLAWI, MO University of Massachusetts Medical School Chief, Surgical Critical Care Fellow in Cardiovascular Medicine Worcester, Massachusetts University of Arizona Health Sciences Division of Cardiology, Department of Center Medicine ROBERT C. HENDEL, BS, MO Tucson, Arizona Northwestern University Associate Professor of Medicine Chicago, Illinois Section of Cardiology WILLIAM B. KANNEL, MO, MPH George Washington University Professor of Medicine and Public Health NAVIN C. NANDA, MO Washington, DC Boston University School of Medicine Professor of Medicine Director, Nuclear Cardiology and Coronary Medical Director, Emeritus Framingham Division of Cardiovascular Disease Care Unit Heart Study Director, Heart StationiEchocardiography Rush Presbyterian-St. Luke's Medical Center Boston, Massachusetts Laboratories Chicago, Illinois University of Alabama at Birmingham OEPING LEE, MO Birmingham, Alabama L. DAVID HILLIS, MO Assistant Professor Professor and Vice Chair Department ofMedicineiResearch Medicine J.V. NIXON, MO, FACC Department oflnternal Medicine University of Southern California Professor oflnternal Medicine University of Texas Southwestern Medical Los Angeles, California Medical College of Virginia Center Virginia Commonwealth University CARL V. LEIER, MO Dallas, Texas Director, Echocardiography Laboratories Professor oflnternal Medicine Medical College of Virginia Hospitals NORMAN K. HOLLENBERG, MO Ohio State University Richmond, Virginia Professor of Medicine Staff Cardiologist Harvard Medical School Ohio State University Medical Center JOHN B. O'CONNELL, MO Director of Physiologic Research Columbus, Ohio Professor and Chairman Brigham and Women's Hospital Department of Medicine MARTIN M. LEWINTER, MO Boston, Massachusetts University of Mississippi Medical School Director of Cardiology Jackson, Mississippi THOMAS A. HOLLY, MO Professor of Medicine Assistant Professor of Medicine University of Vermont College of Medicine ADEFISAYO ODUWOLE, MO Division of Cardiology, Department of Burlington, Vermont Assistant Professor of Medicine Medicine Morehouse School of Medicine A. JAMES LIEDTKE, MO Northwestern University Atlanta, Georgia Professor of Medicine Chicago, Illinois Department of Medicine ELIZABETH OFILI, MO, MPH HOWARD R. HORN, MO University of Wisconsin Medical School Professor of Medicine The LW Diggs Alumni Professor of Madison, Wisconsin Chief of Cardiology Medicine Morehouse School of Medicine JOY L. LOGAN, MO Chair of Excellence in Medical Education Atlanta, Georgia Associate Professor of Medicine Department of Medicine/Cardiology University of Arizona JAE K. OH, MO University of Tennessee at Memphis School of Medicine Staff Nephrologist Professor oflnternal Medicine Senior Physician University of Arizona Health Sciences Center Mayo Medical School University of Tennessee Health Sciences Tucson, Arizona Consultant Center Mayo Clinic ROBERT G. LUKE, MO Memphis, Tennessee Rochester, Minnesota Taylor Professor of Medicine Department oflnternal Medicine University of Cincinnati College of Medicine Director, University Hospital Inc. Cincinnati, Ohio tV BRIAN OLSHANSKY, MD CLIFFORD J. ROSEN, MD PAUL D. STEIN, MD Professor Professor Director of Research Department ofInternal Medicine Department of Nutrition St. Joseph Mercy-Oakland Hospital University ofIowa University of Maine Pontiac, Michigan Director, Cardiac Electrophysiology Orono, Maine NEIL J. STONE, MD University ofIowa Hospitals St. Joseph's Hospital Professor of Clinical Medicine Iowa City, Iowa Bangor, Maine Division of Cardiology PETER OTT, MD JOHN SPEER SCHROEDER, MD Department of Medicine Assistant Professor of Medicine Professor of Medicine Northwestern University Medical School Department of Medicine/Cardiology Department of Medicine Chicago, Illinois University of Ariwna Stanford University School of Medicine TOMASZ STYS, MD Director, Electrophysiology Lab Stanford, California Fellow University Medical Center ERNST R. SCHWARZ, MD, FECS Department of Medicine Tucson, Arizona Associate Professor of Medicine, Med. State University of New York Health JOHN A. PARASKOS, MD Clinic I Sciences Center Professor of Medicine RWTH University Hospital Stony Brook, New York Department of Medicine Aachen, Germany University of Massachusetts Medical School Chairman of Cardiology JAY M. SULLIVAN, MD t Chief, Division of Cardiology Director of Ambulatory Cardiology Dr. S. Fakeeh Hospital (Harvard Medical Professor of Medicine University of Massachusetts Memorial International) University of Tennessee College of Medicine Health Care Jeddah, Saudi Arabia Senior Physician Worcester, Massachusetts SUSAN SIMANDl, MD University of Tennessee Health Sciences THOMAS J. PICKERING, MD, DPHll Assistant Professor of Medicine Center Professor of Medicine Department of Medicine Memphis, Tennessee Department of Medicine State University of New York Health PAUL T. VAITKUS, MD The Cornell University Medical College Sciences Center New York, New York Stony Brook, N ew York Professor Case Western Reserve University School of WilLIAM R. PITTS, MD SIDNEY C. SMITH, JR., MD Medicine Senior Fellow Professor of Medicine Cardiology Division Department of Cardiology University of North Carolina University Hospitals of Cleveland University of Texas Southwestern Medical Director, Cardiovascular Center Cleveland, Ohio Center University of North Carolina Hospitals PANTEL S. VOKONAS, MD Dallas, Texas Chapel Hill, North Carolina Professor of Medicine and Public Health ERIC N. PRYSTOWSKY, MD ERIK C. SKOREL, MD Boston University School of Medicine Consulting Professor of Medicine Fellow Director, Department of Veteran Affairs Duke University Medical Center Department of Cardiology, Med. I Normative Aging Study Durham, North Carolina; RWTH University Boston, Massachusetts Director, Clinical Electrophysiology Aachen, Germany PARK W. WilLIS, IV, MD Laboratory JOHN A. SPITTEll, JR., MD, MACP, FACC Professor of Medicine and Pediatrics St. Vincent's Hospital Professor Emeritus Associate Chief of Cardiology Indianapolis, Indiana Division of Cardiovascular Diseases University of North Carolina School of TIMOTHY J. REGAN, MD Mayo Medical School Medicine Professor of Medicine Consultant, Mayo Clinic Chapel Hill, North Carolina Department of Medicine Rochester, Minnesota GREGG M. YAMADA, MD University of Medicine and Dentistry of PETER C. SPITTEll, MD, FACC Assistant Clinical Professor of Medicine New Jersey Assistant Professor of Medicine University of Hawaii Newark, New Jersey Division of Cardiovascular Diseases Pacific Cardiology, LLC STUART RICH, MD Department ofInternal Medicine Private Practice Professor of Medicine Mayo Medical School Honolulu, Hawaii Department of Cardiology Rochester, Minnesota Rush Medical College tdeceased KELLY ANNE SPRATT, DO Director, Rush Heart Institute Assistant Professor Center for Pulmonary Heart Disease Department of Medicine Rush Presbyterian-St. Luke's Medical University of Pennsylvania Center Director, Women's Cardiovascular Health Chicago, Illinois Presbyterian Medical Center Philadelphia, Pennsylvania v Preface This third edition of Cardiology for the Primary Care Physi cover, or it can employed as a reference aid when a particu cian contains much that is new. Each of the chapter lar problem is encountered. authors has revisited his or her chapter, adding up-to-date As with all scholarly activities, this text is the result of close material and references and deleting obsolete information. collaboration between the authors, the editor, and the Two new chapters have been added. The text is full of the publisher. Many individuals have contributed to its creation. I latest diagnostic and therapeutic concepts that should be would like to acknowledge in particular the outstanding useful to the clinically active primary care physician. Cardi efforts of Barbara Raney, Charlene Sass, Lisa Janda, and ology for the Primary Care Physician can be read cover-to- Annmarie D'Ortona. Joseph S. Alpert, MD Tucson, Arizona vz Contents CHAPTER 1 CHAPTER 12 ------------- Evaluating the Patient with Risk Factors for and Prevention of Cardiovascular Disease .....................1 Atherosclerotic Cardiovascular Disease ........9 7 Joseph S. Alpert Pantel S. Vokonas and William B. Kannel CHAPTER 2 CHAPTER 13 ------------ Referrals ................................1 3 The Effect of Exercise on the Heart and the Julius}. Chosy Athlete's Heart ..........................1 07 Barry A. Franklin and Gerald F. Fletcher CHAPTER 3 Preoperative Consultation ..................1 7 CHAPTER 14 ------------- Maher Nahlawi and Thomas A. Holly Approach to the Patient with Hyperlipidemia .........................1 15 CHAPTER 4 Neil}. Stone Interpreting Noninvasive Cardiac Tests ........2 5 Robert C. Hendel CHAPTER 15 ------------- Evaluation and Management of the CHAPTER 5 Patient with Hypertension .................1 33 Evaluation of the Patient with Robert G. Luke Nontraumatic Chest Pain ...................3 7 John A. Paraskos CHAPTER 16 -------------- Secondary Hypertension ..................1 43 CHAPTER 6 Thomas G. Pickering and Norman K. Hollenberg Evaluation of the Patient with Heart Failure ... .47 Carl V. Leier CHAPTER 17 -------------- Pheochromocytoma ......................1 51 CHAPTER 7 Vincent DeQuattro and Deping Lee Evaluation of the Patient with Hypotension and Shock ....................5 7 CHAPTER 18 -------------- Richard C. Becker Chronic Ischemic Heart Disease ............1 61 Thomasz Stys, Susan Simandl, and Peter F. Cohn CHAPTER 8 Evaluation of the Patient with Palpitations and CHAPTER 19 ------------- Non-life-threatening Cardiac Arrhythmias .....6 5 Unstable Angina and Non-Q-Wave Kelly Anne Spratt and Eric L. Michelson Myocardial Infarction ....................1 71 John Speer Schroeder CHAPTER 9 Evaluation of the Patient with Syncope ........7 3 CHAPTER 20 -------------- Charles M. Blatt and Thomas B. Graboys Q-Wave Myocardial Infarction .............1 77 Ernst R. Schwarz and Erik C. Skobel CHAPTER 10 ------------ Evaluation of the Patient Resuscitated CHAPTER 21 ------------- from Cardiac Arrest ...................... .79 Mitral Stenosis and Regurgitation ...........1 95 Peter Ott and Eric N. Prystowsky Sidney C. Smith Jr. and Park W. Willis, IV CHAPTER 11 -------------- CHAPTER 22 ------------- Evaluation of the Patient with Edema. : ........8 9 Mitral Valve Prolapse .....................2 03 Michael H. Humphreys and Joy L. Logan Richard B. Devereux Vll CHAPTER 23 CHAPTER 36 Aortic Stenosis and Regurgitation ...........2 13 Nonpenetrating Cardiac Trauma ............3 37 Michael A. Fifer Steven B. Johnson and A. James Liedtke CHAPTER 24 CHAPTER 37 Tricuspid and Pulmonic Valve Disease ........2 23 Diseases of the Aorta .....................3 47 William R. Pitts and L. David Hillis Gregg M. Yamada and Joseph S. Alpert CHAPTER 25 CHAPTER 38 Hypertrophic Cardiomyopathy .............2 29 Diseases of the Peripheral Arteries and Veins .. 353 Gregg M. Yamada and Joseph S. Alpert John A. Spittel/, Jr. and Peter C. Spittell CHAPTER 26 CHAPTER 39 Congestive Cardiomyopathy ...............2 35 Anticoagulation, Acute and Chronic: Mohammad Asif and Timothy}. Regan Indications and Methods ..................3 63 Jack E. Ansell CHAPTER 27 Restrictive Cardiomyopathy ................2 47 CHAPTER 40 Martin E. Goldman and Edward A. Fisher Cerebrovascular Complications of Cardiac Disorders .......................3 75 CHAPTER 28 Seemant Chaturvedi and Marc Fisher Infectious Myocarditis ....................2 59 Martin E. Goldman CHAPTER 41 The Heart and Endocrine Diseases ...........3 81 CHAPTER 29 Clifford J. Rosen Infectious Endocarditis ....................2 71 Gordon A. Ewy CHAPTER 42 Rheumatic Diseases and the Heart ...........3 91 CHAPTER 30 David F. Giansiracusa, Deborah M. DeMarco, Pericardial Disease .......................2 79 and Leslie R. Harrold Jae K. Oh, Paul T. Vaitkus, Martin M. LeWinter, and Joseph S. Alpert CHAPTER 43 The Aging Heart .........................4 01 CHAPTER 31 J. V. Nixon Congenital Heart Disease, Including Unrepaired lesions in the Adult .............2 89 CHAPTER 44 Melvin D. Cheitlin and John A. Paraskos Pregnancy and the Heart ..................4 11 Brad S. Burlew, Howard R. Horn, and CHAPTER 32 Jay M. Sullivan Congenital Heart Disease in the Adult Postoperative Patient ................3 05 CHAPTER 45 John S. Child and Joseph S. Alpert The Transplanted Heart ...................4 17 Charles K. Moore, John B. O'Connell, and CHAPTER 33 Joseph S. Alpert Pulmonary Hypertension ..................3 13 Stuart Rich CHAPTER 46 Atrial Fibrillation: Practical Approaches ......4 27 CHAPTER 34 Hongsheng M. Guo, Omer A. Bajwa, Pulmonary Embolism .....................3 19 and Brian Olshansky Paul D. Stein and Russell D. Hull Index .................................4 41 CHAPTER 35 ------------- Cardiac Tumors ........................ .329 Elizabeth o. Ofi ii, Adafisayo Odulwole, and Navin C. Nanda VllZ Evaluating the Patient with Cardiovascular Disease Joseph S. Alpert II hi t ry i the rno I important diagn Ii t t r. r makin the eorre t diRb'T10 i . len i lion or h rt ailure. in in the eircuLati n all w the Lini ian tenti Ie onomi or pc onal eo I or particular th t the te t wiU b definili\'e in making the The evaluation of a cardiovascular patient involves a careful history, physical examination, and laboratory studies such as chest radiogram, electrocardiogram (ECG), and a number of standard blood tests (eg, a lipid profile). More special ized procedures, such as a Doppler echocardiographic study, enable the physician to make a precise cardiovascular diagnosis. Because specialized diagnostic tests are often expensive and can entail significant risk for the patient, they are usually reserved for individuals with clinically significant or symptomatic cardiovascular disease. Such tests are chosen with an eye to their cost-benefit ratio, including test-related morbidity. THE CARDIOVASCULAR HISTORY The history is the most important diagnostic tool for making the right diagno sis. A correct diagnosis can be made in more than 50% of patients after a careful history is taken. With a detailed history, the physician seeks to understand the abnormal physiology that is producing the patient's symptoms. For example, when asking a patient about chest pain, the examiner should determine the specific quality, frequency, duration, and location of the pain, as well as precipi tating factors related to it (eg,inspiration, recumbence, exertion, or emotional upset). A family history of heart disease, hypertension, diabetes mellitus, sudden death, rheumatic fever, congenital heart lesions, or lipid disorder often suggests hereditary predisposition to cardiovascular disease. In addition, physicians should estimate the level of functional disability resulting from the patient's symptoms. Consider the difficulty that the patient experiences in carrying out the tasks of daily living. The level of disability is often expressed in terms of the traditional New York Heart Association Func tional Classification, which includes four classes of functional ability and disabil ity (Table 1). Another system for classifying disability divides functional class into four levels that relate to specific activities and metabolic equivalents (METs) (Table 2). Moreover, very specific functional status can be heart or to lung disease. Indeed, many patients may have obtained by measuring total body oxygen consumption coexisting heart and lung disease such as COPD and (V02) at peak obtainable exercise levels. coronary artery disease (CAD). Information from the patient's history (eg, previous myocardial infarction (MI) or rheumatic fever), the physical examination, and labora SPECIFIC CARDIOVASCULAR SYMPTOMS tory results (eg, findings on the chest radiograph indicative of severe chronic lung disease) help to establish the cause Dyspnea of dyspnea. Dyspnea is shortness of breath out of proportion to the Chest Discomfort level of exertion. Common causes of dyspnea include left ventricular (LV) failure, mitral or aortic valve disease, and Coronary artery disease is a common cause of chest acute or chronic pulmonary disease, such as chronic discomfort. Decisions about diagnostic testing and patient obstructive pulmonary disease (COPD) or asthma. Other management depend on estimations of the likelihood that a frequently observed causes of dyspnea include pulmonary patient's chest discomfort is caused by ischemic heart embolism, interstitial lung disease, and anxiety. Patients disease. The physician should decide whether the patient is with cardiac dyspnea often complain of associated orthop having angina pectoris. Determining factors are specific nea or paroxysmal nocturnal dyspnea. In some patients, it characteristics of the chest pain: central location; radiation may be difficult to decide whether dyspnea is secondary to to arms, neck, or jaw; and a squeezing, pressing, or indiges tion-like character. If the discomfort is predictably brought on by exertion, relieved by rest or nitroglycerin, and is TAIII[ 1 TII[ N,w YOfH< HlMU A. . "o( IATION severe enough to cause the patient to cease activity, the FUNCTlONhl CtA .... HIChIlON or H[AIH OI<;[A"[ diagnosis is probably exertional angina. If the pain occurs spontaneously, is less predictably relieved by rest or nitro glycerin, and is milder, the patient may have atypical ardiac tatu Progno i angina. If the pain is not anginal in nature, the patient is n mpromi ed said to have chest discomfort of noncardiac origin. light! mpr mi d , ith themp' The discomfort of MI is usually similar to that associ loderatcl compromi ed ir with themp ated with angina pectoris, although it is generally more mpr mi ed uarded ~ ith therapy severe and is often accompanied by dyspnea, nausea, or diaphoresis. Chest pain associated with pulmonary dis or- TI\III1 "l. A rUNC IIONhl CI" .,.,IIIChIiON Of H£A"I I)I'rA~I· la Minut on re:admi1lt p cifi tivity 1 .mying 2 -Ib bje -t up eight tep. 10 Walking mi arrving O-Ib objc I 8 hovcling ntl' ,spading dirt 11 -6 V allun~" milh Raking, W edin~ the garden :tuaJ inter' urse arrving an hmg lip eight rep. II 1-) tnppmg and making bed Pu hmg \ cr lu\ n mower howcring without IIlpplllg alking 2.5 mi re mg With ut toppin!!: IV < 1 m: of the above °8 d nn til I' n nl' b,lIII II> rnul m I hall dtm lid I>f '8ro t 1'<010<"01. J'C'lld~d In hum;n8 1 ml WlIlin. 2 Cardiology for the Primary Care Physician
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