Site Tour
A severe case of indigestion
Initial presentation
You are working in an emergency department when a 55 year old male patient presents complaining of severe indigestion pain that awoke him from sleep 30 minutes ago. He describes the pain as a constant pressure located behind the breastbone that is not relieved by position or breathing.
Further information
The patient is triaged using the Australasian Triage Scale. He is assigned a Category Two status requiring immediate transfer to a monitored area and urgent medical review. Further history is obtained from the patient.
The pain is constant, not related to movement or breathing and radiates to left arm and to jaw. There is associated dyspnoea and sweatiness. Although he has long history of indigestion chest pain he reports that this pain became began more quickly (he awoke with the pain), is more severe and feels different from his indigestion. He reports no exercise related pain.
He has a past medical history of an inguinal hernia operation (5 years previously) and has recently been diagnosed with hypertension. He continues to smoke a 20 cigarettes / day and his brother (aged 52 years) recently underwent bypass surgery on the heart. His only medication is an antihypertensive drug (an ACE Inhibitor).
Question
History is a key element in assessing a patient for the possibility of acute myocardial infarction or unstable angina. The term Acute Coronary Syndrome (ACS) is applied to the patient with persistent chest pain due to myocardial ischaemia because in the absence of definitive ECG changes it is not possible in the first few hours to distinguish between acute myocardial infarction (characterised by necrosis or death of cardiac muscle) and angina (due to reversible ischaemia and resulting in no permanent damage to cardiac muscle).
Biochemical markers of cardiac necrosis (most commonly Troponin) are used to determine whether infarction of myocardium has occurred. As it takes between 8 and 12 hours after the onset of the ischaemia for these to reliably detect (or exclude) myocardial damage history continues to have a central role in the assessment of the patient presenting with chest pain.
As the "quality" of the pain can be quite variable ranging from the classic heavy/pressure type pain to pain described as sharp or burning it is important to consider the broad clinical picture and determine whether as a whole it points more toward pain due to acute coronary syndrome (ie most of its elements are consistent with ACS ie the pain is typical or suspicious) or whether the reverse applies with most of the components more commonly associated with non cardiac chest pain (ie the pain is atypical).
Features typical for pain due to acute coronary syndrome include all the following except
| Sudden onset, maximal intensity at the onset of pain. |
|
| Pain localised to the left chest wall (ie located over the heart) |
|
Constant unremitting pain |
|
Poorly localised pain often radiating to jaw, neck or left arm |
|
Unaffected by posture, breathing, food or antacids |
Select your answer by clicking one of the buttons