Key Feature 3: In a patient with unexplained chest pain, rule out ischemic heart disease.
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Investigation
Ischemic Heart Disease
Key Feature 3: In a patient presenting with symptoms suggestive of ischemic heart disease but in whom the diagnosis may not be obvious, do not eliminate the diagnosis solely because of tests with limited specificity and sensitivity (ex: electrocardiography, exercise stress testing, normal enzyme results).
Skill: Selectivity, Clinical Reasoning
Phase: Diagnosis, Investigation
Key Feature 6: In a person with diagnosed acute coronary syndrome (ex: cardiogenic shock, arrhythmia, pulmonary edema, acute myocardial infarction, unstable angina), manage the condition in an appropriate and timely manner.
In the patient who presents to clinic with a history of chest pain, the features listed below should raise your suspicion that the pain is secondary to cardiac ischemia, per UpToDate:
However well the episode(s) of chest pain fit the above descriptors, this can help you determine your pretest probability of the chest pain being secondary to cardiac ischemia. The following table suggests a way of categorizing pretest probability:
If you are concerned for active cardiac ischemia and a possible myocardial infarction (MI) then you need to send any patient who comes into your outpatient office to the emergency for the appropriate workup and treatment (see last post). In the patient who presents without ongoing ischemic chest pain but in whom you suspect they may have ischemic heart disease, the next step is generally to get a baseline ECG and then refer them for cardiac stress testing. If the initial workup, either in the acute or stable patient, is negative for ischemic heart disease, be it via ECG, cardiac biomarkers, or stress testing, remember that the tests can be falsely negative. If you are still suspicious for ischemic heart disease, consider further testing with repeat ECG, repeat cardiac biomarkers, and/or coronary angiography. See the algorithm and table below for investigation and workup of suspected acute coronary syndrome. The institution at which you are working may also have a protocol for acute chest pain and suspected ACS. Consider using a Grace or TIMI score (on your medical calculator app) for risk stratification. If you think a patient may be having complications of acute coronary syndrome, see these past blog posts for management of an arrhythmia or cardiogenic shock.
See this Life in the Fast Lane post about left bundle branch blocks.