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Case 1: Diagnostic Evaluation of Chest Pain

A 65-year-old man presented to the emergency department with a complaint of left-sided chest pain radiating to his left arm. There were no alleviating factors. His past medical history included hypertension, uncontrolled diabetes mellitus, and hyperlipidemia. He denied any toxic habits. His baseline exercise tolerance is 2 city blocks limited by fatigue. Upon presentation, vital signs were stable and the physical examination was unremarkable. The chest pain was partially relieved by sublingual nitroglycerin. The 12-lead ECG showed nonspecific T-wave inversions in the inferolateral leads. He was administered aspirin, and the chest pain resolved shortly thereafter. Subsequently, he was admitted to the telemetry floor for further evaluation and observation. His serial cardiac biomarkers were negative. He did not have any recurrent chest pain and remained hemodynamically stable throughout the hospital stay. How would you manage this case?

Case Review

In this clinical scenario, the patient does not fit the complete picture of anginal symptoms. However, the key here is the presence of risk factors and subtle 12-lead ECG changes, which place him at an elevated risk for coronary artery disease. He can be further evaluated by stress testing for risk stratification.

Case Discussion

Angina consists of retrosternal chest pain increased by activity or emotional stress and generally relieved by rest or administration of nitroglycerin. The evaluation of chest pain begins with a thorough history and physical examination to delineate the etiology. The list of differential diagnoses is vast, and a detailed review of systems about pertinent diagnoses can narrow down the list. The presence of comorbid conditions and risk factors might hint toward a diagnosis of coronary artery disease. Both serial 12-lead ECG and highly sensitive cardiac troponin T testing should be performed before excluding ongoing ischemic coronary artery disease. Prior to stress testing, the patient should be chest pain free for 24 hours, without dynamic 12-lead ECG changes, and the highly sensitive cardiac troponin T level should be negative or trending downward.

The differential diagnosis of chest pain includes the following:

  • Coronary artery disease

  • Aortic dissection

  • Pericarditis

  • Pneumonia

  • Pulmonary embolism

  • Costochondritis/rib fracture

  • Peptic ulcer disease

  • Acute cholecystitis

  • Cervical radiculopathy

  • Herpes zoster

  • Anxiety disorder

Key Points

  • Chest pain should be classified as anginal or nonanginal based on the history.

  • Anginal symptoms can be considered in the setting of risk factors and should be evaluated by an appropriate stress modality if the symptoms are vague.

  • Serial 12-lead ECG and highly sensitive cardiac troponin T should be performed to exclude ongoing ischemic coronary artery disease before stress testing is performed.

Case 2: Diagnosis of Acute Coronary Syndrome

A 56-year-old obese man presented to the emergency department with a complaint of central chest pain awakening him from sleep. He has a past medical history of hypertension and bronchial asthma. In ...

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