++
For further information, see CMDT Part 2-05: Chest Pain
++
Pain onset, character, location/size, duration, periodicity, and exacerbating factors
Shortness of breath
Vital signs; chest and cardiac examination
Electrocardiogram and 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
Precocious acute coronary syndrome (ACS)
Occurs in patients aged 35 years or younger
May represent acute thrombosis independent of underlying atherosclerotic disease
Risk factors are obesity, familial hypercholesterolemia, cigarette use, and myocardial bridging (often associated with left ventricular hypertrophy)
Because pulmonary embolism (PE) 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
Sickle cell anemia
Carbon monoxide poisoning
++
Ischemic cardiac pain symptoms
Dull, aching sensation of "pressure," "tightness," "squeezing," or "gas," rather than a sharp or spasmodic pain
Usually subside within 5–20 minutes but may last longer
May be accompanied by a sense of anxiety or uneasiness
Retrosternal or left precordial in location but pain may be referred to the
Throat
Lower jaw
Shoulders
Inner arms
Upper abdomen
Back
May be precipitated or exacerbated by exertion, cold temperature, meals, stress, or combinations of these factors
Usually relieved by rest
Uncommon for pain to reach maximum intensity in seconds
Prolonged chest pain episodes might represent myocardial infarction, although up to one-third of patients with acute myocardial infarction do not report chest pain
Progressive symptoms or symptoms at rest may represent unstable angina
Acute coronary syndrome (ACS)
A broader range of symptoms are more common in older adults, women, and persons with diabetes
Chest discomfort at rest
Most common presenting symptom of ACS, reported by 79% of men and 74% of women
Dull, aching sensation of “pressure,” “tightness,” “squeezing,” or “gas,” rather than sharp or spasmodic
Up to one-third of patients with acute myocardial infarction do not report chest pain
Shortness of breath
Dizziness
Anxiety, such as a feeling of impending doom
Vagal symptoms, such as nausea and diaphoresis
In older adults, fatigue is a common presenting complaint of ACS
Women with ACS are more likely than men to present with three or more associated symptoms (eg. epigastric symptoms; palpitations; and pain or discomfort in the jaw, neck, arms, or between the shoulder blades)
Hypertrophy of either ventricle or aortic stenosis may also ...