From the Guidelines
The patient should undergo immediate evaluation for acute coronary syndrome (ACS) with ECG, cardiac biomarkers, and continuous cardiac monitoring, given the concerning presentation of crushing generalized abdominal pain, back pressure, nausea, lightheadedness, and numbness and tingling in the right arm, which occurred during exercise and resolved after 20 minutes, in the context of a family history of heart disease and personal history of GERD and PTSD. The symptoms suggest cardiac ischemia, although the abdominal component could indicate GERD exacerbation or referred cardiac pain.
Initial Steps
- Immediate ECG to evaluate for signs of ischemia or infarction 1
- Cardiac biomarkers (troponin series) to assess for myocardial injury 1
- Complete blood count and basic metabolic panel to evaluate for other potential causes of symptoms
- Chest X-ray to assess for pulmonary causes of symptoms
Additional Testing
- Stress test or coronary angiography depending on initial findings to evaluate for coronary artery disease 1
- Consideration of non-invasive cardiac imaging modalities, such as multidetector CT or MRI, if initial tests are negative but clinical suspicion remains high 1
Management
- Aspirin 325mg if not contraindicated to reduce risk of further cardiac events 1
- Nitroglycerin for acute symptoms, beta-blockers, and high-intensity statins if cardiac etiology is confirmed 1
- Proton pump inhibitors to address GERD symptoms
- Continuation of PTSD management to mitigate stress response and potential exacerbation of cardiac symptoms
Patient Education
- Education on recognition of cardiac symptoms and when to seek emergency care is essential for ongoing management 1
- Discussion of the importance of calling 9-1-1 immediately if symptoms recur or worsen 1
From the Research
Initial Assessment and Workup
The patient's symptoms of crushing generalized abdominal pain, back pressure, nausea, lightheadedness, and numbness and tingling in the right arm, which occurred during exercise and resolved after 20 minutes, warrant a thorough evaluation for potential acute coronary syndrome (ACS) and other cardiovascular conditions 2, 3, 4. The patient's family history of heart disease and personal history of GERD and PTSD should also be considered in the workup.
Diagnostic Tests
- Electrocardiography (ECG) should be performed immediately to distinguish between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS) 2, 4.
- High-sensitivity troponin measurements should be obtained to evaluate for NSTEMI 2.
- Further diagnostic testing, such as stress tests or computed tomography angiography, may be considered if ACS is suspected but not confirmed by initial tests 3.
Risk Stratification
The patient's risk factors, including family history of heart disease, GERD, and PTSD, should be taken into account when assessing the likelihood of ACS and determining the appropriate management strategy 2, 3, 5.
Management
- Aspirin should be administered as soon as possible if there are no contraindications, and the patient should be considered for antiplatelet therapy and beta blockers if indicated 2, 4.
- If STEMI is diagnosed, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes should be performed, or fibrinolytic therapy should be administered if PCI is not available 2, 4.
- For high-risk patients with NSTE-ACS, prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours may be considered 2, 3.
Consideration of Other Conditions
The patient's symptoms could also be indicative of other conditions, such as aortic dissection, which may be misdiagnosed as ACS 6. The patient's PTSD history may also be relevant, as PTSD has been associated with an increased risk of cardiovascular disease and may impact the patient's response to treatment 5.