Chest Pain and Emergency Medicine Presentation and Risk Stratification
Coronary artery disease can present in multiple different ways. You can have someone present that is so ill that no one would miss the diagnosis. They are ashen gray, writhing around with chest pain, and are sweaty, looking like they are knocking on death's door. No one can miss that diagnosis. This patient is so ill I call it "janitor sign.: This patient is so sick, that even if the janitor walked in the room, they would say, "this guy is having a heart attack!"!" But, on the other side of the coin, you can also have someone who presents with indigestion. There are patients that are so grossly atypical for a presentation of an acute coronary syndrome that they are easily misdiagnosed. I have seen it way too many times in my career, these patients with an atypical, non-text book like presentation. I now know you have to entertain and acute coronary syndrome in anybody with chest symptoms, be it chest pain, shortness of breath or indigestion.
The key is to stack the deck with cardiac risk factors. The cardiac risk factors (or arterial risk factors) are easily recalled by the mnemonic, "SAD CHF." S is smoking, A is age, D is diabetes, C is cholesterol, H is hypertension and F is family history. Don't cause a terrible outcome by missing an acute coronary syndrome. The presentation of the patient with chest pain can be extremely varied, so risk factor analysis is critical. Type A personality, obesity or a sedentary lifestyle; these are less objective cardiac risk factors. But, these are less tangible and difficult to quantify. Remember, the astute provider will also quality these risk factors. A much less risk factor is a patient with early, or diet controlled diabetes. It's another to be an insulin dependent diabetic for 20 years. It's one thing to have poorly controlled hypertension, it's another to carry the diagnosis of hypertension and be well controlled.
Remember, apply your cardiac risk factors when you evaluate a patient with chest pain. If a patient has a number of risk factors, they have an increased risk of ischemic heart disease.
How many cardiac risk factors does this patient have? 46 yo male with a history or osteoarthritis, migraine headaches, Elevated blood pressure presents with atypical like chest pain?
How else would you evaluate this patient?