From the Guidelines
The patient presenting with right-sided chest pain, pyrosis, diaphoresis, and palpitations should be immediately evaluated with an electrocardiogram (ECG) to rule out acute coronary syndromes (ACS), followed by a thorough history, physical examination, and targeted diagnostic tests. The clinical presentation of acute coronary syndromes is broad, ranging from cardiac arrest to patients who are already pain-free at the time of presentation, with the leading symptom being acute chest discomfort described as pain, pressure, tightness, and burning 1. Given the patient's symptoms, including chest pain, heartburn, cold sweats, and palpitations with a slightly elevated pulse, it is crucial to consider both cardiac and gastrointestinal causes.
The patient's symptoms could be indicative of non-ST-segment elevation ACS (NSTE-ACS), which exhibits ECG changes that may include transient ST-segment elevation or depression, T-wave inversion, or no ECG changes at all 1. Echocardiography can be a valuable bedside technique in the triage of patients with acute chest pain, helping to identify acute myocardial ischemia and other major causes of chest pain such as acute aortic dissection, pericardial effusion, and pulmonary embolism 1.
Key steps in the diagnostic approach include:
- Assessing the character, duration, and exacerbating/relieving factors of the chest pain
- Complete review of systems and medical history, including cardiac risk factors
- Immediate ECG to rule out acute cardiac conditions
- Basic laboratory tests including cardiac enzymes (troponin, CK-MB), complete blood count, comprehensive metabolic panel, and thyroid function tests
- Chest X-ray to evaluate for pulmonary pathology
- Consideration of stress testing, echocardiogram, or cardiac CT angiography if cardiac etiology is suspected but initial tests are inconclusive
- Evaluation for possible gastrointestinal causes related to the heartburn, such as an upper GI series or endoscopy
This systematic approach, guided by the most recent and highest quality evidence 1, helps differentiate between life-threatening cardiac conditions and other causes, ensuring appropriate management based on the underlying diagnosis.
From the Research
Diagnosis of Chest Pain
The patient's symptoms of right-sided chest pain, pyrosis (heartburn), diaphoresis (cold sweats), and palpitations, with normal vitals and a slight tachycardia, can be indicative of several conditions.
- The presence of chest pain that is not reproduced with palpation and is accompanied by other symptoms such as diaphoresis and palpitations may suggest a cardiac origin 2, 3, 4.
- However, the presence of pyrosis (heartburn) could also indicate a non-cardiac cause, such as gastroesophageal reflux disease (GERD), which is a common cause of non-cardiac chest pain 3.
- The diagnosis of acute coronary syndrome (ACS) is considered based on symptoms, electrocardiography changes, and elevated troponin levels 2, 4, 5.
- A validated risk score, such as the Thrombolysis in Myocardial Infarction score, may also be useful in assessing the likelihood of ACS 4.
- Further testing, such as exercise treadmill testing, stress myocardial perfusion study, stress echocardiography, and computed tomography, may be necessary to rule out coronary artery disease 4, 6.
Differential Diagnosis
The differential diagnosis for the patient's symptoms includes:
- Acute coronary syndrome (ACS) 2, 4
- Gastroesophageal reflux disease (GERD) 3
- Unstable angina 2, 3
- Myocardial infarction (MI) 4, 5
- Non-cardiac chest pain 3, 6
Diagnostic Evaluation
The diagnostic evaluation of the patient should include:
- Electrocardiography (ECG) to assess for ST-segment elevation or depression, T-wave inversion, or presence of Q waves 2, 4
- Serum cardiac troponin measurements to assess for elevated levels 2, 4, 5
- Risk stratification tools, such as the Thrombolysis in Myocardial Infarction score, to assess the likelihood of ACS 4
- Further testing, such as exercise treadmill testing, stress myocardial perfusion study, stress echocardiography, and computed tomography, to rule out coronary artery disease 4, 6