Chest Pain..When of cardiac origin

For patients presenting to the ED with chest pain, we've been taught that “classic” or “typical” presentations for ACS (chest pressure with radiation to the left neck/jaw/shoulder/arm, dyspnea, diaphoresis, nausea, vomiting, lightheadedness) are most worrisome. Yet, many of the patients that present with typical symptoms end up having negative workups for ACS. What are the symptoms that truly predict ACS? Three major studies have demonstrated that the best predictors of ACS in patients presenting to the ED with chest pain are (not necessarily ranked in order):

1. chest pain that radiates to the arms, especially if the pain radiates bilaterally or to the right arm
2. chest pain associated with diaphoresis
3. chest pain associated with vomiting
4. chest pain associated with exertion

The description of the chest pain (e.g. "pressure" or "squeezing," etc.), the dyspnea, nausea, lightheadedness, and pain at rest were, surprisingly, not helpful at predicting ACS.

The simple takehome point is the following: always ask your patient with chest pain if the pain radiates, if there was associated diaphoresis, if there was associated vomiting, and if the pain is associated with exertion. If the answers to any of these 4 questions is "yes," think twice before labeling the patient with a non-ACS diagnosis.

References

1. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 2005;294:2623-2629.

2. Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation 2010;81:281-286.

3. Panju AA, Hemmelgarn BR, Guyatt GH, et al. Is this patient having a myocardial infarction? JAMA 1998;280:1256-1263.

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