What is the diagnosis for a patient presenting with right-sided chest discomfort, pyrosis (heartburn), diaphoresis (cold sweats), palpitations, nausea, and weakness, with normal vitals and mild tachycardia (elevated pulse)?

From the Guidelines

The patient's presentation of right-sided chest discomfort, pyrosis, diaphoresis, palpitations, nausea, and weakness, with normal vitals and mild tachycardia, warrants an immediate cardiac workup to rule out acute coronary syndrome, as the combination of symptoms could indicate a cardiac event. According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1, chest pain that is more likely associated with ischemia consists of substernal chest discomfort provoked by exertion or emotional stress and relieved by rest or nitroglycerin. Although the patient's right-sided chest discomfort is atypical for cardiac pain, it is essential to consider the possibility of referred pain from cardiac ischemia.

Key aspects of the patient's symptoms that suggest a potential cardiac origin include:

• Chest discomfort
• Diaphoresis
• Palpitations
• Weakness
• Elevated pulse

To evaluate the patient's symptoms, the following steps should be taken:

• Order an ECG immediately to rule out acute coronary syndrome
• Basic laboratory tests should include cardiac enzymes (troponin, CK-MB), complete blood count, basic metabolic panel, and liver function tests
• Consider a chest X-ray to evaluate for pulmonary causes
• If cardiac workup is negative, pursue gastrointestinal evaluation with an upper endoscopy to assess for GERD, gastritis, or peptic ulcer disease that could explain the heartburn and nausea

It is crucial to prioritize the cardiac workup, as the patient's symptoms could indicate a life-threatening cardiac condition. The guideline emphasizes the importance of specific aspects of symptoms that suggest their origin in terms of probable ischemia 1. While waiting for test results, provide symptomatic relief with antacids for heartburn if appropriate. The diagnostic approach should focus on ruling out life-threatening cardiac conditions first before investigating other potential causes like gastrointestinal disorders, pulmonary issues, anxiety, or musculoskeletal pain.

From the Research

Diagnosis of Chest Pain

The patient's symptoms of right-sided chest discomfort, pyrosis (heartburn), diaphoresis (cold sweats), palpitations, nausea, and weakness, with normal vitals and mild tachycardia, can be indicative of several conditions.

• The symptoms of heartburn and regurgitation are suggestive of gastroesophageal reflux disease (GERD) as the cause of chest pain 2.
• The presence of chest pain, diaphoresis, and palpitations can also be indicative of cardiac origin, such as angina pectoris or acute coronary syndrome (ACS) 3, 4, 5.
• The patient's symptoms can be evaluated using the Marburg Heart Score and the INTERCHEST clinical decision rule to estimate the risk of ACS 4.
• A 12-lead electrocardiography can be used to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions, which can help diagnose ACS 4.
• The History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) risk scores can also be used to diagnose ACS 5.

Differential Diagnosis

The differential diagnosis for the patient's symptoms includes:

• GERD, which can be diagnosed using the omeprazole test or upper endoscopy 2.
• Cardiac conditions such as angina pectoris or ACS, which can be diagnosed using exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging 3, 4, 5.
• Other non-cardiac conditions such as chest wall pain or costochondritis, panic disorder or anxiety states, acute pericarditis, pneumonia, heart failure, pulmonary embolism, and acute thoracic aortic dissection 4, 6.

Diagnostic Approach

The diagnostic approach for the patient's symptoms should include:

• A thorough medical history and physical examination to identify any underlying conditions that may be causing the symptoms 3, 4, 6.
• The use of risk scores such as the HEART or TIMI score to estimate the risk of ACS 5.
• Diagnostic tests such as 12-lead electrocardiography, exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging to diagnose cardiac conditions 3, 4, 5.
• The use of the omeprazole test or upper endoscopy to diagnose GERD 2.