1. In a patient with undifferentiated chest pain, assess for life-threatening diagnoses first and promptly recognize clinical presentations that clearly suggest these diagnoses (e.g., ACS, PE, pneumothorax, aortic dissection).
Potentially Life threatening chest pain ddx:
- Unstable angina / AMI
- Aortic dissection = asymmetry or absence of pulse & new diastolic murmur
- Tension Pneumothorax
- Esophageal rupture = hamman’s crunch
- pericarditis / tamponade = Pericardial friction rub
Aortic dissection CXR
- widened mediastinum
- intimal calcium separation (extension of aortic shadow>5mm beyond calcified aortic wall)
- L pleural effusion
- Lost of aortic knob
2. In a patient with undifferentiated chest pain, initiate rapid treatment and investigation of possible diagnoses as they arise, even though the history may be incomplete (e.g., early ASA if possible ACS, early ECG).
3. In a patient with undifferentiated chest pain, perform a detailed history of the characteristics of the pain and associated symptoms to help distinguish serious from benign diagnoses, and to generate the appropriate differential diagnosis for the patient.
Angina – typically substernal, crushing chest pain with radiation to neck, arms, jaw, dyspnea, diaphoresis and exacerbated by exertion or stress
- burning/indigestion (30%) & sharp/stabbing (17%)
Coronary vasospasm (Prinzmetal’s) – c/p precipitated by cold or during sleep
Dyspnea, diaphoresis, tachycardia and S4 are often associated findings in significant angina
- crescendo angina
- angina at rest
- new onset angina
4. In a patient with undifferentiated chest pain, identify risk factors that may affect the pre-test probability of important possible diagnoses such as ACS or pulmonary embolus.
Risk factors for IHD
- family hx
- SLE / RA
- Chronic alcoholism
Risk factors for PE (Well’s)
- HR >100
- Immobilization >=3d or surgery in previous 4 wk
- Previous PE/DVT dx
- Malignancy w/ Tx w/in 6mo or palliative
- clinical signs and symptoms of DVT / PE is #1 dx
5. In a patient with undifferentiated chest pain, do not rule out important diagnoses based on unreliable clinical features or early test results (e.g., chest wall tenderness, response to a “pink lady,” normal cardiac enzymes, normal ECG, normal CXR, negative D-dimer).