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6 Anomalous Coronary Arteries
123
2014 Jun;35(5):778-84. https://doi.org/10.1007/s00246-013-0852-8. PMID:
24337706. http://www.ncbi.nlm.nih.gov/pubmed/24337706 **
Latus H, Gummel K, Rupp S, Mueller M, Jux C, Kerst G, Akintuerk H, Bauer J,
Schranz D, Apitz C.Cardiovascular magnetic resonance assessment of ventricular function and myocardial scarring before and early after repair of anomalous
left coronary artery from the pulmonary artery. J Cardiovasc Magn Reson. 2014
Jan 5;16:3.
https://doi.org/10.1186/1532-429X-16-3. PMID: 24387660. http://
www.ncbi.nlm.nih.gov/pubmed/24387660 **
Kazmierczak PA, Ostrowska K, Dryzek P, Moll JA, Moll JJ.Repair of anomalous
origin of the left coronary artery from the pulmonary artery in infants. Interact
Cardiovasc Thorac Surg. 2013 Jun;16(6):797-801. https://doi.org/10.1093/icvts/
ivt061. PMID: 23442939. http://www.ncbi.nlm.nih.gov/pubmed/23442939 **
Alexi-Meskishvili V, Nasseri BA, Nordmeyer S, Schmitt B, Weng YG, Böttcher W,
Hübler M, Berger F, Hetzer R.Repair of anomalous origin of the left coronary
artery from the pulmonary artery in infants and children. J Thorac Cardiovasc
Surg. 2011 Oct;142(4):868-74. https://doi.org/10.1016/j.jtcvs.2011.04.006.
PMID: 21665229. http://www.ncbi.nlm.nih.gov/pubmed/21665229
Browne LP, Kearney D, Taylor MD, Chung T, Slesnick TC, Nutting AC,
Krishnamurthy R.ALCAPA: the role of myocardial viability studies in determining prognosis. Pediatr Radiol. 2010 Feb;40(2):163-7. https://doi.
org/10.1007/s00247-009-1412-5. PMID: 19795113. http://www.ncbi.nlm.nih.
gov/pubmed/19795113 **
Case Study
Lam JC, Giuffre M, Myers KA. Late intervention in an asymptomatic pediatric
patient with anomalous left coronary artery. World J Cardiol. 2014 Aug
26;6(8):874- 7.
www.ncbi.nlm.nih.gov/pubmed/25228967 **
Szmigielska A, Roszkowska-Blaim M, Goáąbek-Dylewska M, Tomik A, Brzewski
M, Werner B. Bland-White-Garland syndrome - a rare and serious cause of
failure to thrive. Am J Case Rep. 2013 Sep 16;14:370-2. https://doi.org/10.12659/
AJCR.889112. PMID: 2408679. http://www.ncbi.nlm.nih.gov/
pubmed/24086793 **
Varghese M, Kothari S.The caveats in the diagnosis of anomalous origin of left
coronary artery from pulmonary artery (ALCAPA). Images Paediatr Cardiol.
2010 Jul;12(3):3-8. PMID: 22368564. http://www.ncbi.nlm.nih.gov/
pubmed/22368564 **
Kurup RP, Daniel R, Kumar RK.Anomalous origin of the left coronary artery from
the pulmonary artery in infancy with preserved left ventricular function: Potential
pitfalls and clues to diagnosis. Ann Pediatr Cardiol. 2008 Jan;1(1):65-7. https://
doi.org/10.4103/0974-2069.41061
gov/pubmed/20300243 **
https://doi.org/10.4330/wjc.v6.i8.874. PMID: 25228967. http://
. PMID: 20300243. http://www.ncbi.nlm.nih.
124
R. M. Cantor et al.
Brotherton H, Philip RK.Anomalous left coronary artery from pulmonary artery
(ALCAPA) in infants: a 5-year review in a dened birth cohort. Eur J Pediatr.
2008 Jan;167(1):43-6. PMID: 18038147. http://www.ncbi.nlm.nih.gov/
pubmed/18038147
**
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
“Bland White Garland Syndrome”[Mesh] OR “ALCAPA” OR “Bland White
Garland”
Chapter 7
Anxiety
CharlesV.Pollack,Jr.,RichardM.Cantor, andVictoriaG.Riese
Name andSynonyms
Anxiety, anxiety disorder, panic disorder, panic attacks
Incidence/Epidemiology
• Anxiety disorder is a very common psychiatric condition. It often manifests
through physical symptoms; chest pain +/- dyspnea/hyperventilation +/- palpitations is a common presentation of anxiety disorder.
• There is no good estimate of the incidence of anxiety as a cause of chest pain
that prompts medical evaluation.
• Around 25 % of individuals are thought to experience at least one panic attack
in their lifetimes.
C. V. Pollack,Jr. ()
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
R. M. Cantor
Department of Emergency Medicine and Pediatrics, State University of NewYork Upstate
Medical University, Syracuse, NY, USA
V. G. Riese
Librarian Consultant, Eldersburg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_7
125© Springer Nature Switzerland AG 2019
126
C. V. Pollack, Jr. et al.
Differential Diagnosis
• Presentation can be quite dramatic. The differential considerations for chest
pain due to anxiety therefore include immediate life threats such as pulmonary embolism, acute coronary syndrome, and aortic dissection. Less severe
differential considerations include pneumonia and pneumothorax, which can
cause pleuritic pain; and chest wall pain.
Pathophysiology andEtiology
• Current thinking is that anxiety and panic result from an imbalance in CNS
neurotransmitters.
• The diagnosis of anxiety as an etiology for chest pain that prompts medical
evaluation should be made only after more serious causes have been evaluated
and reasonably excluded.
Presentation
Typical/“Classic”
• The classic presentation of anxiety- or panic-related chest pain is:
• Acute onset
• Associated with dyspnea (the patient may confuse hyperventilation with
dyspnea)
• Associated with diaphoresis
• Trembling or shaking
• Fear of dying
• Sense of loss of control
• Nausea
Atypical
• Patients with anxiety or panic disorder may present with myriad complaints. Chest pain is common among these, but many other features may
be present.
7 Anxiety
Primary Differential Considerations
• The differential diagnosis of acute anxiety is broad and includes both medical
and psychiatric considerations.
• Medical:
• Because acute anxiety may mimic acute somatic disease, one must consider
such immediate life threats as acute myocardial infarction, aortic dissection,
arrhythmias, pulmonary embolism, pneumothorax, or stroke.
• Other concerns include hypo- and hyperglycemia, poisoning and drug
abuse, delirium tremens, and encephalopathy.
• Psychiatric:
• Acute anxiety may be confused with acute psychosis, conversion disorders,
dissociative disorders, schizoaffective disorder, and Tourette’s syndrome.
History andPhysical Exam
Findings That Conrm Diagnosis
127
• History and physical examination are not diagnostic for anxiety.
Factors That Suggest Diagnosis
• Symptoms are out of proportion with physical ndings.
• Patient-reported dyspnea is found on exam to be hyperventilation.
Video overview of the causes and treatment of hyperventilation
https://www.youtube.com/watch?v=p97HeXx0vN0
• History of anxiety or panic disorder.
• Young age and/or lack of risk factors for more serious conditions.
• Choking sensation accompanying chest pain.
• Current substance abuse.
Factors That Exclude Diagnosis
• There are no history or physical ndings that conclusively exclude anxiety as
a cause of chest pain.
128
C. V. Pollack, Jr. et al.
Ancillary Studies
Laboratory
• There are no diagnostic laboratory studies for anxiety.
• Laboratory tests target suspected underlying disease.
Imaging
• There are no diagnostic imaging studies for anxiety.
Special Populations
Age andGender
• The epidemiology of anxiety and panic disorder does not indicate any consistent patterns by age or gender. It may begin at a young age.
• Anxiety disorders are the most common psychiatric disturbances in childhood, usually representing negative outcomes of naturally occurring fears
associated with childhood development.
• The literature describes multiple forms of anxiety disorders in children,
including social anxiety, agoraphobia, panic attacks, separation anxiety,
and specic phobias.
Co-morbidities
• It is important to consider and evaluate for the presence of serious underlying
disease or psychiatric stress that could prompt situation anxiety, such as:
• Recent death of a loved one
• Recent relationship stress
• Recent diagnosis of serious disease
• Other psychiatric issues may be discovered upon questioning.
• Substance abuse issues may be discovered upon questioning.
7 Anxiety
Pitfalls inDiagnosis
Critical Steps Not toMiss
• Because there are differential considerations that are immediate life threats,
evaluation for acute coronary syndrome, pulmonary embolism, and pneumonia should be considered early.
Mimics
• The entire constellation of diagnoses that underlies chest pain syndrome can
mimic or cause the pain and overall presentation of anxiety.
Time-Dependent Interventions
• Other than excluding life threats, there are no time-dependent interventions
for chest pain deemed due to anxiety or panic disorder.
• Patients who also express suicidal or homicidal ideation should be promptly
evaluated in an emergency care setting.
129
Overall Principles ofTreatment
• Treatment of the acute symptoms of chest pain caused by panic or anxiety disorder may include:
• Reassurance and support
• Benzodiazepines
• Monitoring while the effects of acute substance abuse diminish
Disease Course
• The course of patients with anxiety or panic disorder may vary widely,
from no further episodes to debilitating psychiatric illness that limits or
precludes productive engagement with society.
130
C. V. Pollack, Jr. et al.
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
Practice Guideline
Bandelow B, Sher L, Bunevicius R, Hollander E, Kasper S, Zohar J, Möller HJ;
WFSBP Task Force on Mental Disorders in Primary Care; WFSBP Task Force on
Anxiety Disorders, OCD and PTSD.Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress
disorder in primary care. Int J Psychiatry Clin Pract. 2012 Jun;16(2):77–84.
https://doi.org/10.3109/13651501.2012.667114. PMID: 22540422. http://www.
ncbi.nlm.nih.gov/pubmed/22540422 **
Schaffer A, McIntosh D, Goldstein BI, Rector NA, McIntyre RS, Beaulieu S,
Swinson R, Yatham LN; Canadian Network for Mood and Anxiety Treatments
(CANMAT) Task Force. The CANMAT task force recommendations for the
management of patients with mood disorders and comorbid anxiety disorders.
Ann Clin Psychiatry. 2012 Feb;24(1):6–22.. PMID: 22303519. http://www.ncbi.
nlm.nih.gov/pubmed/22303519 **
Review
Combs H, Markman J.Anxiety Disorders in Primary Care. Med Clin North Am.
2014 Sep;98(5):1007–1023. https://doi.org/10.1016/j.mcna.2014.06.003. PMID:
25134870. http://www.ncbi.nlm.nih.gov/pubmed/25134870 **
Stein DJ, Craske MA, Friedman MJ, Phillips KA.Anxiety disorders, obsessive-
compulsive and related disorders, trauma- and stressor-related disorders, and dissociative disorders in DSM-5. Am J Psychiatry. 2014 Jun 1;171(6):611–3. https://
doi.org/10.1176/appi.ajp.2014.14010003. PMID: 24880507. http://www.ncbi.
nlm.nih.gov/pubmed/24880507
McConaghy JR, Oza RS.Outpatient diagnosis of acute chest pain in adults. Am
Fam Physician. 2013 Feb 1;87(3):177–82. PMID: 23418761. http://www.ncbi.
nlm.nih.gov/pubmed/23418761 **
Bystritsky A, Khalsa SS, Cameron ME, Schiffman J.Current diagnosis and treat-
ment of anxiety disorders. P T. 2013 Jan;38(1):30–57. PMID: 23599668. http://
www.ncbi.nlm.nih.gov/pubmed/23599668 **
Hoge EA, Ivkovic A, Fricchione GL.Generalized anxiety disorder: diagnosis and
treatment. BMJ. 2012 Nov 27;345:e7500.
PMID: 23187094.
http://www.ncbi.nlm.nih.gov/pubmed/23187094 **
**
https://doi.org/10.1136/bmj.e7500.
7 Anxiety
131
Kessler RC, Ruscio AM, Shear K, Wittchen HU.Epidemiology of anxiety disorders.
Curr Top Behav Neurosci. 2010;2:21–35. PMID 21309104. http://www.ncbi.
nlm.nih.gov/pubmed/21309104 **
Weisberg RB. Overview of generalized anxiety disorder: epidemiology, presenta-
tion, and course. J Clin Psychiatry. 2009;70 Suppl 2:4–9. PMID: 19371500.
http://www.ncbi.nlm.nih.gov/pubmed/19371500
Case Study
Wolf L.Anxiety is the last diagnosis on the list. J Emerg Nurs. 2010 May;36(3):287–9.
https://doi.org/10.1016/j.jen.2010.01.001. PMID: 20457335. http://www.ncbi.
nlm.nih.gov/pubmed/20457335
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
“Anxiety”[Mesh] OR “Anxiety”
Chapter 8
Aortic Regurgitation
ChristopherJ.Rees, CharlesV.Pollack,Jr., andVictoriaG.Riese
Name andSynonyms
Aortic Regurgitation
• Aortic Insufciency
Incidence/Epidemiology
• The most common causes of aortic regurgitation (AR) in the developed world
are congenital bicuspid aortic valve and aortic root enlargement from diseases
such as Marfan’s syndrome.
• In the developing world, the most common cause of aortic regurgitation is
rheumatic heart disease.
• The prevalence of aortic regurgitation increases with age, with about a 2 %
prevalence of moderate to severe AR in men over 70, and about a 2.5 % prevalence of moderate to severe AR in women over 70.
C. J. Rees
Emergency Department, Pennsylvania Hospital, Philadelphia, PA, USA
C. V. Pollack,
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
V. G. Riese
Librarian Consultant, Eldersburg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_8
Jr. ()
133© Springer Nature Switzerland AG 2019