Priority Topic: Chest Pain & Priority Topic: Ischemic Heart Disease

Chest Pain

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.
Skill: Selectivity
Phase: Treatment

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:

• Angina is usually characterized more as a discomfort (pressure, squeezing, constriction, choking, burning, tightness, knot in throat or chest) rather than pain (sharp, stabbing, pins and needles-like).
• Angina is typically gradual in onset and offset. Once present, it is constant and does not change with position or respiration.
• Angina is not felt in a specific spot, but is usually a diffuse discomfort that may be difficult to localize.
• Angina is usually elicited by activities and situations that increase myocardial oxygen demand.
• Angina generally lasts for two to five minutes.
• Angina is often associated with other symptoms; the most common are shortness of breath, nausea, and diaphoresis.

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.