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Clinical Presentation
Ischemic-type Chest Discomfort or Anginal Equivalent
Retrosternal chest pain is pain that is usually described as heaviness,
pressure, tightness, cramping or burning in nature. It may occur at rest or
during activity that may be associated with physical exertion or emotional
stress. Pain that is usually central or in the left chest may radiate to the
jaw, left or both arms, back or shoulder. Accompanying symptoms of
ischemic-type chest discomfort may include nausea and vomiting, dyspnea,
diaphoresis, lightheadedness, abdominal (epigastric) pain, dizziness, fatigue,
weakness and loss of consciousness.
Chest pain-equivalent symptoms include pain that develops in the arm,
shoulder, wrist, jaw or back without occurrence in the chest. This discomfort
presents solely as jaw, neck, ear, arm, or epigastric pain and is associated
with exertion or stress or is relieved promptly with Glyceryl trinitrate (GTN)
should be considered equivalent to angina.
The pain in ischemic-type chest discomfort is usually not relieved by
rest or GTN. Established risk factors include smoking, dyslipidemia,
hypertension, diabetes, and history of coronary artery disease (CAD).
Please see the discussion on Evaluation
for Risk Stratification.
Acute Coronary Syndromes w.out Persistent ST-Segment Elevation_Intial Assesment
Patients
with ACS may present with a broad range of signs and symptoms, from
asymptomatic at presentation to patients with ongoing chest discomfort (eg
pain, pressure, tightness, heaviness, burning). Patients may also present with
cardiac arrest, electrical or hemodynamic instability or cardiogenic shock. Older patients frequently have an atypical presentation with
symptoms of weakness, confusion, delirium or syncope. Patients typically
present with ischemic-type chest pain as
described above, except episodes may be more severe and prolonged, and may
occur at rest or may be caused by less exertion than previous episodes.
Chest-pain equivalent symptoms are often observed in younger (25 to 40 years
old), and older (>75 years old) patients, in women, and in patients with
diabetes mellitus (DM), chronic renal failure or dementia. Chest
pain-equivalent symptoms include pain that occurs predominantly at rest,
epigastric pain, recent onset of unexplainable indigestion, belching, stabbing
chest pain, chest pain with some pleuritic features or increasing dyspnea.
Common features of UA include:
- Rest angina: Angina occurring at rest and prolonged, usually >20 minutes
- New-onset severe angina: Patient usually has marked limitation on ordinary physical activity (angina occurs on walking one to two blocks on level or climbing one flight of stairs under normal conditions and at a normal pace)
- Increasing or crescendo angina: Previously diagnosed effort-related angina that has become distinctly more frequent, longer in duration or more easily provoked (by less effort than before)
- Post-MI angina
Khám thực thể
The major objectives of doing a physical examination in patients
suspected with ACS is to identify precipitating causes (eg
uncontrolled hypertension, thyrotoxicosis, gastrointestinal [GI] bleeding) and
comorbid conditions (eg lung disease or cancer), to identify very high-risk and
high-risk ACS features, to assess the hemodynamic impact of the ischemic event,
to exclude non-cardiac causes of chest pain (eg pneumothorax, pulmonary
embolism, pneumonia, pleural effusion, esophageal discomfort, gallstones,
pancreatitis, or musculoskeletal origin), and to assess for non-ischemic
cardiac disorders (eg pericarditis, valvular disease, aortic dissection, acute
pericarditis, cardiac tamponade).
Vital signs are also measured (eg blood pressure [BP] in both arms,
heart rate [HR], respiratory rate [RR], and temperature). A thorough cardiovascular
and chest exam are also performed which includes auscultation of the heart,
neck veins, liver, and peripheral pulses to check for murmurs, bruits or pulse
deficits which signify severe underlying CAD. Left
ventricle (LV) dysfunction and shock should be suspected if the patient has
cold extremities, hypotension, pulmonary rales, S3 gallop, displaced
apex beat or S1<S2 at the apex. Aortic dissection may be present if there is
pain in the back, unequal pulses, or a murmur of aortic regurgitation. While
acute pericarditis is suspected by a presence of pericardial friction rub.
Cardiac tamponade may be present as pulsus paradoxus.
Patients with pneumothorax may have acute dyspnea,
pleuritic chest pain, and differential breath sounds. Lastly, chest pain caused
by musculoskeletal chest wall syndromes may be found by performing palpation of
the chest wall.
Diagnosis or Diagnostic Criteria
Diagnosis and initial short-term risk stratification of ACS should be based on clinical history, symptoms, vital signs, and other physical findings, electrocardiogram (ECG) results, and concentration of high-sensitivity cardiac troponin (hs-cTn). It is important that patients with suspected ACS must be evaluated quickly.