Atypical chest pain:
Atypical chest pain may be due to ischemic heart disease (especially unstable angina) however it is less likely to the cardiac in origin. Atypical chest pain may present as following:
· Sharp or knife- like pain brought on by respiratory movements or cough (pleuritic pain).
· Pain that has primary location of discomfort in the middle or lower abdominal region.
· Pain that may be localized at the tip of one finger, particularly over the left ventricular apex.
· Pain produced with movement or palpation of the chest wall or arms.
· Constant pain that persists for many hours.
· Very brief episodes of pain that last a few seconds or less.
· Pain that radiates into the lower extremities.
CHEST PAIN DUE TO MYOCARDIAL INFARCTION:
Pain of myocardial infarction is similar to angina in distribution but it is of longer duration and is usually of greater intensity. In contrast to stable angina it is not relieved by rest or sublingual nitroglycerine. It may be accompanied by nausea, perspiration and hypotension.
Diagnosis and plan of management:
- History: History is very important, ask about risk factors for MI such as hypertension, smoking, diabetes, dyslipidemia and strong family tendency. Decide whether the pain is typical or atypical, acute ongoing pain, recurrent or persistent pain.
- Examination is usually unremarkable.
- ECG: ST depression or elevation.
If clinical suspicion of myocardial ischemia is strong and ECG is normal then keep the patient in observation for 6-12 hours, perform serial ECGs and check cardiac enzymes. After this period further cardiac testing with ETT, or thallium scan helps in making the diagnosis.
Following investigations may be considered to identify the cause of chest pain depending on clinical assessons.
· ECG
· Cardiac enzymes (CK-MB, Troponin T or Troponin I)
· X-ray chest
· X-rays of spine, shoulder or rib
· Echocardiogram
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