History

Routine questions should determine the quality, location, radiation, intensity. frequency, associated symptoms, and precipitating factors of chest pain. For patients who have difficulty explaining symptoms in a narrative fashion, directed questions should be asked. Patients without previously diagnosed ischemic heart disease may have difficulty describing the quality of pain and may resort to textbook terms. Specific questioning is needed about radiation to the jaw, neck, arms, back, or epigastrium. However, lack of such specific pain location is not differentiating. Pain intensity is commonly graded on a scale of 1 to 10, with 10 representing the worst pain the patient can imagine. The frequency of pain episodes should be assessed over a continuum of the past weeks to better determine whether the condition is stable or unstable angina. Patients can be asked about episodes relative to a past holiday or event and should compare frequency to the current time frame. They should identify precipitating factors such as changes with inspiration, movement, palpation, or exertion and during sleep or at rest. The presence of associated symptoms such as diaphoresis, near syncope, nausea, or vomiting raises concern about ischemic disease. Family members, friends, or emergency medical technicians (EMTs) who may have witnessed the episode can be questioned about the patient's general appearance while in pain. If the patient is described as appearing ill, suspicion for ischemia is heightened.

The classic description of angina pectoris is that of a retrosternal left anterior chest or epigastric discomfort consisting of crushing, tightening, squeezing, or pressure. The presence of certain associated symptoms during chest pain—including dyspnea, diaphoresis, nausea, and/or vomiting—is common and indicates a twofold higher risk of ischemia. Many patients also complain of discomfort radiating from the chest to the left shoulder, arm, hand, or jaw, a finding whose presence is also associated with a significantly greater risk of ischemia.45 However, atypical characteristics are the rule rather than the exception. For example, up to 22 percent of patients with AMI describe their symptoms as being sharp or stabbing in character and up to 6 percent describe a pleuritic component of their pain. 6

Anginal pain (or other anginal symptoms) is typically described as lasting from 2 to 20 min and pain from an uncomplicated AMI lasting up to 2 h. In contrast, chest pain that is described as lasting a "split second" or only a few seconds is more likely to be due to another cause, as is constant, unremitting pain lasting 12 to 24 h or more. Anginal pain is often brought on by exertion and relieved by rest, while pain worsened by body movement or body position is suggestive (but certainly not diagnostic) of another etiology. Angina may also occur at rest and is often attributed to coronary artery spasm with or without underlying atherosclerotic lesions.

All patients should also be questioned regarding the presence of cardiac risk factors, although "risks" are valid only for predicting the presence of coronary artery disease within a given population and not in an individual patient. Major risk factors identified by the American Heart Association include age above 40, male or postmenopausal female, hypertension, cigarette smoking, hypercholesterolemia, diabetes, truncal obesity, family history, and sedentary lifestyle. Cocaine use is associated with AMI even in young people with minimal or no coronary artery disease. Chronic cocaine use has also been associated with accelerated atherosclerosis and severe coronary artery disease.

The patient's medical record should always be reviewed when analyzing chest pain. Previous ECGs should always be compared with the current tracing. Results of prior stress testing, echocardiograms, catherizations, or radionuclide scans should be reviewed, if available, and the present symptoms interpreted in light of those results. The "gold standard" for determining the presence or absence of coronary artery disease is angiography. In general, catherization reports from within the previous 2 years are considered to be generally reflective of the current extent of disease.

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