Chest Pain And Emergency Medicine Presentation And Risk Stratification

If you evaluate cardiac patients, you know that ischemic heart disease is the number one killer of people in America.

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 deaths door. No one can miss that diagnosis. I call that janitor sign, meaning the patients are so ill, that if the janitor walk into the room, the janitor would say, you better get in here, this guys 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. It has happened countless times in my career, these patients that present in an atypical way. 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 arterial risk factors, for any arterial pathology, be it a heart attack or stroke, can be remembered 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. Understand the presentation can be varied, and that risk factors 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. Its another to be an insulin dependent diabetic for 20 years. Its one thing to have poorly controlled hypertension, its 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. The more risk factors a patient has, the more you have to weight their risk of having an acute coronary syndrome.

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?

What other questions would you ask for risk factor analysis?

by: Carl Davidson

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