| Diagnosis | Historical features | Examination findings | Electrocardiogram | Chest radiograph | Additional tests | Additional important information |
| Acute coronary syndrome | - Substernal/left-sided chest pressure or tightness is common
- Onset is gradual
- Pain radiating to shoulders or pain with exertion increases the likelihood of ACS
- "Atypical" symptoms (eg, dyspnea, weakness) more common in older adults, women, diabetics
- Older adults can present with dyspnea, weakness, syncope, or ΔMS alone
| - Nonspecific
- May detect signs of HF
| - ST segment elevations, Q waves, new left bundle branch block are evidence of AMI
- Single ECG is not sensitive for ACS
- Prominent R waves with ST segment depressions in V1 and V2 strongly suggests posterior AMI
| - Nonspecific
- May show evidence of HF
| - Troponin elevations are sensitive (but not specific) for diagnosis of AMI
- Single set of biomarkers is not sufficiently sensitive to rule out AMI (unless negative high-sensitivity troponin obtained 2 or 3 hours after pain onset)
| - Assume symptoms of ACS within days or a few weeks of PCI or CABG is from an occluded artery or graft.
- Cardiogenic shock, which is most commonly caused by AMI and has a high mortality, occurs when the heart cannot pump adequate amounts of blood to provide tissue perfusion.
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| Aortic dissection | - Sudden onset of sharp, tearing, or ripping pain
- Maximal severity at onset
- Most often begins in chest, can begin in back or progress to abdominal pain
- Can cause ischemic stroke, ACS, mesenteric ischemia, or mimic kidney stone
- Up to 10% with neurologic symptoms but without chest pain
- Syncope occurs in 5-10%
| - Absent upper extremity or carotid pulse or large discrepancy in systolic blood pressure between extremities is suggestive*
- May develop new diastolic murmur associated with acute aortic regurgitation
- Findings vary with arteries affected or from mass effect
- Up to 30% with neurologic findings, such as stroke, altered mental status, Horner syndrome, paraplegia (spinal cord ischemia), or hoarseness (vocal cord paralysis)
| - Ischemic changes in 15%
- Nonspecific ST and T changes in 30%
| - Wide mediastinum or loss of normal aortic knob contour is common (up to 76%)
- 10% have normal CXR
| | - Can mimic many diseases depending on branch arteries involved (eg, AMI, stroke).
|
| Pulmonary embolism | - Many possible presentations, including pleuritic pain and painless dyspnea
- Often sudden onset
- Dyspnea often dominant feature
| - No finding is sensitive or specific
- Extremity exam generally normal
- Lung exam generally nonspecific; focal wheezing may be present; tachypnea is common
| - Usually abnormal but nonspecific
- Signs of right heart strain suggestive (eg, RAD, RBBB, RAE)
| - Great majority are normal
- May show atelectasis, elevated hemidiaphragm, pleural effusion
| - A D-dimer is useful to rule out PE only when negative in low to intermediate risk patients
- Bedside cardiac ultrasound may show right heart strain and wall motion abnormalities in patients with massive or submassive PE
| |
| Tension pneumothorax | - Often sudden onset
- Initial pain often sharp and pleuritic
- Dyspnea often dominant feature
| - Ipsilateral diminished or absent breath sounds
- Subcutaneous emphysema is uncommon
| | - Demonstrates air in pleural space
| | |
| Pericardial tamponade | - Pain from pericarditis is most often sharp anterior chest pain made worse by inspiration or lying supine and relieved by sitting forward
- Dyspnea is common
| - Severe tamponade creates obstructive shock and causes jugular venous distension, pulsus paradoxus
- May hear friction rub
| - Decreased voltage and electrical alternans can appear with significant effusions
- Diffuse PR segment depressions and/or ST segment elevations can appear with acute pericarditis
| - May reveal enlarged heart
| - Ultrasound reveals pericardial effusion with tamponade
| |
| Mediastinitis (esophageal rupture) | - Forceful vomiting often precedes esophageal rupture
- Recent upper endoscopy or instrumentation increases risk of perforation
- Odontogenic infection is possible cause
- Coexistent respiratory and gastrointestinal complaints may occur
| - Ill-appearing; shock; fever
- May hear (Hamman's) crunch over mediastinum
| | - Large majority have some abnormality: pneumomediastinum, pleural effusion, pneumothorax
| | |
| Myocarditis | - Highly variable clinical manifestations
- Chest pain may reflect associated pericarditis or mimic ischemia
- Can have myalgias or history of recent upper respiratory tract infection or enteritis
- Fatigue and decreased exercise capacity often precede HF
| - No specific physical examination findings
- In patients with HF, there may be signs of fluid overload and other evidence of cardiac dysfunction (eg, a third heart sound)
- Pericardial friction rub may be detected if associated pericarditis
| - May be normal or show nonspecific abnormalities such as ST changes, atrial or ventricular ectopic beats, or ventricular dysrhythmias
- May be consistent with acute isolated pericarditis
- High grade AV block suggests cardiac sarcoidosis, or idiopathic giant cell myocarditis
| - May be normal or reveal enlarged heart with or without pulmonary vascular congestion and pleural effusion
| - Cardiac biomarkers and acute phase reactants
- Cardiac imaging study (echocardiography, coronary angiography, and/or cardiac magnetic resonance)
| - Can occasionally be severe and cause dilated cardiomyopathy with LV dysfunction, cardiogenic shock, dysrhythmias, and sudden death.
|
| Stress (takotsubo) cardiomyopathy | - Mimics presentation of AMI
- Frequently but not always triggered by intense emotional or physical stress
| - Similar to AMI
- May show signs of heart failure or significant mitral regurgitation
- May have LV outflow tract obstruction, induced by LV basal hyperkinesis, produces a late peaking systolic murmur
| - ST-elevation is frequent, occurring most commonly in the anterior precordial leads (similar to ST-elevation MI)
- ST-depression or T wave inversion can occur but are less common
| | - High-sensitivity troponin will be elevated
- Cardiac imaging study (eg, echocardiography, cardiac magnetic resonance) shows transient LV systolic dysfunction (hypokinesis, akinesis, or dyskinesis)
- Wall motion abnormalities are typically regional and extend beyond a single epicardial coronary distribution
- Absence of obstructive coronary disease on coronary angiography, often performed urgently for ST-elevations
| - The risk of severe in-hospital complications is similar to that in patients with ACS and includes acute HF with cardiogenic shock, dysrhythmia, ventricular and papillary muscle rupture, tamponade, and stroke.
- Patients who survive an acute episode typically recover systolic LV function within one to four weeks. The risk of recurrence of approximately 1 to 2% per year.
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| Perforated peptic ulcer | - Sudden, severe chest and/or abdominal pain
| - Tachycardia
- Abdominal tenderness/ rigidity (may be missing if retroperitoneal perforation)
- Abdominal exam may be less severe if perforation is retroperitoneal or contained
| | - Often shows pneumoperitoneum
| - Posterior perforation into pancreas will result in lipase elevation
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