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ESSENTIAL INQUIRIES

  • Pain onset, character, location/size, duration, periodicity, and exacerbators; shortness of breath.

  • Vital signs; chest and cardiac examination.

  • Electrocardiography and biomarkers of myocardial necrosis in selected patients.

GENERAL CONSIDERATIONS

Chest pain (or chest discomfort) is a common symptom that can occur as a result of cardiovascular, pulmonary, pleural, or musculoskeletal disease; esophageal or other gastrointestinal disorders (including a foreign body, eg, a fish bone); herpes zoster; cocaine use; or anxiety states. The frequency and distribution of life-threatening causes of chest pain, such as acute coronary syndrome (ACS), pericarditis, aortic dissection, vasospastic angina, pulmonary embolism, pneumonia, and esophageal perforation, vary substantially between clinical settings. In the Netherlands and Belgium, chest pain was the reason for consulting the general practitioner in 1.26% of all cases. In 8.4% of patients with chest pain, life-threatening underlying causes were identified. Systemic lupus erythematosus, rheumatoid arthritis, reduced estimated glomerular filtration rate, and HIV infection are conditions that confer a strong risk of coronary artery disease. Precocious ACS may represent acute thrombosis independent of underlying atherosclerotic disease. In patients aged 35 years or younger, risk factors for ACS are obesity, hyperlipidemia, and smoking.

Chest pain characteristics that can lead to early diagnosis of acute myocardial infarction do not differ in frequency or strength of association between men and women. Because pulmonary embolism can present with a wide variety of symptoms, consideration of the 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, and family history and prior history of VTE. Other conditions associated with increased risk of pulmonary embolism include HF and COPD. Sickle cell anemia can cause acute chest syndrome. Patients with this syndrome often have chest pain, fever, and cough.

CLINICAL FINDINGS

A. Symptoms

Myocardial ischemia is usually described as a dull, aching sensation of “pressure,” “tightness,” “squeezing,” or “gas,” rather than as sharp or spasmodic. 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. When present, pain due to myocardial ischemia is commonly accompanied by a sense of anxiety or uneasiness. The location is 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, or back. Ischemic pain may be precipitated or exacerbated by exertion, cold temperature, meals, stress, or combinations of these factors and is usually relieved by rest. However, many episodes do not conform to these patterns, and atypical presentations of ACS are more common in older adults, women, and persons with diabetes mellitus. Other symptoms that are associated ...

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