Differential Diagnosis for Chest Pain and Palpitations

The patient presents with chest pain, a feeling of heaviness, and palpitations, which are concerning symptoms that warrant a thorough evaluation. Based on the provided history, physical examination, and electrocardiography findings, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Atrial Flutter: The electrocardiography showing a "saw tooth pattern of P waves" is highly suggestive of atrial flutter. This condition is characterized by a rapid, regular atrial rhythm, which can lead to symptoms of palpitations and, occasionally, chest discomfort due to the rapid heart rate. The patient's history of coronary artery disease and previous stent placement also increases the risk for arrhythmias like atrial flutter.

• Other Likely Diagnoses

  • Atrial Fibrillation: Although the ECG description is more typical of atrial flutter, atrial fibrillation is a common arrhythmia in patients with a history of coronary artery disease and could present with similar symptoms. However, atrial fibrillation typically shows an irregularly irregular rhythm on ECG, which is not described here.
  • Coronary Artery Disease (Acute Coronary Syndrome): Given the patient's history of coronary artery disease, any new onset of chest pain or discomfort should prompt consideration of an acute coronary syndrome, even though the ECG findings and lack of shortness of breath or syncope make this less likely.

• Do Not Miss Diagnoses

  • Myocardial Infarction (MI): Although the patient's symptoms and ECG findings do not strongly suggest an MI, it is crucial to rule out this diagnosis due to its high morbidity and mortality. The patient's history of coronary artery disease increases his risk for MI.
  • Pulmonary Embolism: While the patient does not have shortness of breath or syncope, and the lung fields are clear, pulmonary embolism can sometimes present atypically, especially in older adults. It is a potentially life-threatening condition that must be considered.

• Rare Diagnoses

  • Mitral Valve Prolapse: This condition can cause palpitations and chest discomfort but is less likely given the specific ECG findings and the lack of a murmur on physical examination.
  • Aortic Stenosis: Typically presents with symptoms of heart failure, syncope, or angina. The absence of a murmur and the specific ECG findings make this diagnosis less likely.
  • Torsades de Pointes: A rare but life-threatening arrhythmia that can cause palpitations and chest discomfort. However, it is characterized by a distinctive ECG pattern not described in this scenario.