ment. Patients with potential cardiac presentations

frequently complain of pain that is worse with exertion

and improved with rest. Pain that is worse with cough or

deep inspiration (pleuritic pain) is typically associated

with either pleurisy, a musculoskeletal etiology, or pulmo ­

nary embolism. Epigastric pain that is worse with meals

usually signifies a gastrointestinal etiology. Pain that is

aggravated by emotional stress may point to an underlying

psychiatric etiology. Finally, inquire about any associated

symptoms. For example, nausea and diaphoresis have been

associated with a higher likelihood for ACS.

Unfortunately, the long-term risk factors for underlying

heart disease (high cholesterol, smoking, hypertension, diabetes, family history) have not been shown to help in the

differentiation of acute chest pain patients in the ED. Nonetheless, this history should be taken. A history of an underlying hypercoagulable state ( eg, pregnancy, malignancy) should

alert you to a possible pulmonary embolism (PE), whereas a

history of an underlying connective tissue disorder ( eg,

Marfan syndrome) should prompt an evaluation for aortic

dissection. Ask about any illicit drug habits, as cocaine use

has been associated with accelerated atherosclerosis, acute

MI, and aortic dissection.

� Physical Examination

Note the general appearance of the patient. Those with

ACS or other serious etiologies may be clutching their

chest and frequently appear anxious, pale, and diaphoretic.

This "sick vs not sick" mentality will guide the rapidity of

your examination. As with all emergency patients, assess

the vital signs and ensure adequate airway, breathing, and

circulation (ABCs). Note abnormal vital signs to help

guide your differential diagnosis. A detailed examination

of the heart, lungs, abdomen, extremities, and neurologic

systems will ensure that no emergent causes of chest pain

are overlooked. Listed next are some emergent presenta ­

tions matched with potential physical exam findings.

ACS. Vital signs will vary widely depending on the re ­

gion of ischemia or infarction. For example, an inferior

wall MI may present with bradycardia and hypotension

owing to increased vagal tone. Murmurs and abnormal

heart sounds such as an S3 or S4 may be present. I nspiratory crackles on 1 ung exam are consistent with secondary

pulmonary edema.

Tension pneumothorax. Look for the classic signs of

decreased breath sounds, tracheal deviation, and res piratory distress. Consider spontaneous pneumothorax in

young, thin patients with an acute onset of chest pain

and shortness of breath.

Pericardia! tamponade. Although usually limited to

patients in extremis, patients may exhibit the classic

signs of Beck's triad (hypotension, diminished heart

CHEST PAIN

sounds, and jugular venous distension). Pulsus paradoxus > 10 mmHg has shown a high sensitivity but low

specificity for tamponade, as any condition causing increased intrathoracic pressure may demonstrate this.

Pulmonary embolism. Dyspnea is the most common

complaint of patients with PE. They may also describe a

pleuritic-type chest pain, especially those with segmental

PEs that cause secondary infarction of the parietal pleura.

Patients with significantly large (massive or submassive)

PE are generally ill-appearing and hemodynamically unstable owing to the sudden severe increase in pulmonary

vascular resistance. A detailed examination of the heart

and lungs may reveal rales, gallops, or a prominent P2.

Lower extremity exam may reveal unilateral swelling consistent with a deep venous thrombosis.

Aortic dissection. The pain is often most severe at onset

and typically extends above and below the diaphragm.

These patients are often hypertensive and may have a

pulse deficit in either the radial and/or femoral arteries.

A marked discrepancy in blood pressure compared between each arm (>20 mmHg) is highly suggestive.

DIAGNOSTIC STUDIES

Perform an electrocardiogram (ECG) within 10 minutes of

presentation for all patients who complain of chest pain or

have signs and symptoms concerning for ACS. Obtain cardiac

markers including a troponin assay ± CK-MB analysis in all

patients with suspected ACS. D-dimer can aid the evaluation

of low-risk patients in whom PE is a diagnostic possibility.

CXR should be ordered on most patients in the ED with

chest pain. Posteroanterior and lateral views are ideal, but a

portable anteroposterior view is sufficient for patients who

require continuous cardiac monitoring. Acute aortic dissection may present with a widened mediastinum or abnormal

aortic contour. Pneumothoraces and subcutaneous air are

readily identified. Pneumomediastinum ± a left-sided pleural

effusion (owing to the relative thinness of the left esophageal

wall) is seen with esophageal rupture (Boerhaave syndrome).