| 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 relative risk
- "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 (or CK-MB, if troponin unavailable) elevations diagnose AMI
- Single set of biomarkers is not sufficiently sensitive to rule out AMI
| - Assume symptoms of ACS within days or a few weeks of PCI or CABG is from an occluded artery or graft
|
| Aortic dissection | - Sudden onset of sharp, tearing, or ripping pain
- Maximal severity at onset
- Most often begins in chest, can begin in back
- Can mimic stroke, ACS, mesenteric ischemia, kidney stone
| - Absent upper extremity or carotid pulse is suggestive
- Discrepancy in systolic BP >20 mmHg between right and left upper extremity is suggestive
- Up to 30% with neurologic findings
- Findings vary with arteries affected
| - 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 high-sensitivity D-dimer is useful to rule out PE only when negative in low-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
- Pericardial effusion can cause 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
| | |
