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Key Features

Essentials of Diagnosis

  • Inquire about

    • Pain onset, character, location/size, duration, periodicity, and exacerbating factors

    • Shortness of breath

  • Vital signs

  • Chest and cardiac examination

  • Electrocardiogram

  • Biomarkers of myocardial necrosis

General Considerations

  • Can occur as a result of

    • Cardiovascular, pulmonary, pleural, or musculoskeletal disease

    • Esophageal or other gastrointestinal disorders

    • Herpes zoster

    • Cocaine use

    • Anxiety states

  • Conditions that confer a strong risk for coronary artery disease

    • Diabetes mellitus

    • Systemic lupus erythematosus

    • Rheumatoid arthritis

    • Reduced estimated glomerular filtration rate (eGFR)

    • HIV

  • Because pulmonary embolism can present with a wide variety of symptoms, consideration of this diagnosis and rigorous risk factor assessment for venous thromboembolism (VTE) is critical

  • Classic VTE risk factors include

    • Cancer

    • Trauma

    • Recent surgery

    • Prolonged immobilization

    • Pregnancy

    • Oral contraceptives

    • Family history

    • Prior history of VTE

  • Other conditions associated with increased risk of pulmonary embolism include heart failure and chronic obstructive pulmonary disease

  • Sickle cell anemia can cause acute chest syndrome

Clinical Findings

Symptoms

  • Myocardial ischemia is usually described as dull, aching sensation of "pressure," "tightness," "squeezing," or "gas," rather than as a sharp or spasmodic pain

  • Ischemic symptoms usually subside within 5–20 minutes but may last longer

  • Progressive symptoms or symptoms at rest may represent unstable angina

  • Prolonged chest pain episodes might represent myocardial infarction, although up to one-third of patients with acute myocardial infarction do not report chest pain

  • Pain due to myocardial ischemia is

    • Commonly accompanied by a sense of anxiety or uneasiness

    • Usually retrosternal or left precordial

  • Because the heart lacks somatic innervation, precise localization of pain due to cardiac ischemia is difficult; the pain is commonly referred to the

    • Throat

    • Lower jaw

    • Shoulders

    • Inner arms

    • Upper abdomen

    • Back

  • Ischemic pain

    • May be precipitated or exacerbated by exertion, cold temperature, meals, stress, or combinations of these factors

    • Usually relieved by rest

  • Atypical presentations of acute coronary syndrome (ACS) are more common in the elderly, women, and persons with diabetes

  • Other symptoms that are associated with ACS

    • Shortness of breath

    • Dizziness

    • Anxiety, such as a feeling of impending doom

    • Vagal symptoms, such as nausea and diaphoresis

  • In the elderly, fatigue is a common presenting complaint of ACS

  • Likelihood ratios for cardinal symptoms considered in the evaluation of acute myocardial infarction are summarized in Table 2–5

  • Hypertrophy of either ventricle or aortic stenosis may also give rise to chest pain with less typical features

  • Pericarditis may produce pain that is greater when supine than upright and may increase with respiration, coughing, or swallowing

  • Aortic dissection

    • Classically produces an abrupt onset of tearing pain of great intensity that often radiates to the back

    • Anterior aortic dissection can also lead to myocardial or cerebrovascular ischemia

  • Rupture of the thoracic esophagus iatrogenically or secondary to vomiting is another cause of chest pain

Table 2–5.Likelihood ratios (LRs) for clinical features associated with acute myocardial infarction.

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