What are the potential causes and management of crushing chest pain with palpable peripheral pulses?

Crushing Chest Pain with Palpable Peripheral Pulses: Differential Diagnosis and Management

When crushing chest pain occurs with all peripheral pulses intact, acute coronary syndrome (ACS) remains the most critical diagnosis to rule out, as an uncomplicated myocardial infarction may present with a completely normal physical examination. 1

Life-Threatening Causes to Consider Immediately

The presence of palpable peripheral pulses significantly reduces—but does not eliminate—the probability of certain catastrophic conditions:

Acute Coronary Syndrome (Most Likely)

• ACS is the primary concern and can present with entirely normal physical findings in uncomplicated cases. 1
• The physical examination contributes almost nothing to diagnosing a heart attack unless shock is present. 1
• Crushing chest pain with intact pulses is entirely consistent with ST-elevation myocardial infarction (STEMI) or non-ST-elevation ACS (NSTE-ACS). 1
• Associated features that increase ACS likelihood include: diaphoresis, nausea, vomiting, radiation to arm/jaw/neck, and symptoms interrupting normal activity. 1

Aortic Dissection (Less Likely but Critical)

• While pulse differential occurs in only 30% of aortic dissection cases, the presence of all peripheral pulses does NOT exclude this diagnosis. 1
• Type B dissections have pulse differentials less frequently than Type A. 1
• Look for: sudden onset of severe "ripping" or "tearing" pain, radiation to the back, history of hypertension, connective tissue disorders (Marfan syndrome), or known bicuspid aortic valve. 1

Pulmonary Embolism

• PE typically presents with tachycardia and dyspnea in >90% of patients, with pleuritic chest pain. 1
• Peripheral pulses remain intact in PE. 1

Other Cardiac Causes with Normal Pulses

• Pericarditis: Pain increases in supine position, may have friction rub, often pleuritic in nature. 1
• Stress cardiomyopathy (Takotsubo): Presents identically to ACS with normal peripheral examination. 1

Immediate Management Protocol

First 10 Minutes

• Activate 9-1-1 immediately and transport by EMS to nearest emergency department. 1, 2, 3
• Obtain and interpret ECG within 10 minutes of arrival to identify STEMI, new left bundle branch block, ST-segment changes, or T-wave inversions. 1, 2, 3
• Place patient on cardiac monitor with resuscitation equipment immediately available. 2, 3
• Administer aspirin 250-500mg (chewable or water-soluble) unless contraindicated. 1, 2, 3

Concurrent Actions

• Establish IV access and draw cardiac troponin (T or I), complete blood count, and basic chemistry. 2
• Obtain vital signs: blood pressure, heart rate, respiratory rate, oxygen saturation, temperature. 2
• Provide supplemental oxygen if saturation <94%. 2
• Administer morphine IV for severe pain, titrated to effect. 2

Diagnostic Evaluation

• Obtain chest X-ray to evaluate for pneumothorax, pneumonia, pleural effusion, or widened mediastinum (suggesting aortic dissection). 2
• Perform bedside echocardiography if available, particularly with hemodynamic instability or new murmurs. 2
• Consider CT angiography if aortic dissection remains in differential despite normal pulses. 2

Risk Stratification for ACS

High-risk features requiring immediate intervention include: 2

• ST-segment elevation or new left bundle branch block on ECG
• Recurrent ischemia (ongoing pain or dynamic ECG changes)
• Elevated troponin levels
• Hemodynamic instability (hypotension, pulmonary edema)
• Major arrhythmias (ventricular tachycardia/fibrillation)

Critical Pitfalls to Avoid

• Do not rely on pain severity to determine urgency—severity is a poor predictor of imminent complications like cardiac arrest. 2, 3
• Never delay treatment waiting for definitive diagnosis in patients with red flags. 2, 3
• Do not discharge patients with normal initial ECG without serial troponin measurements 6-12 hours apart. 2
• The absence of pulse differential does NOT rule out aortic dissection—it is present in only 30% of cases. 1
• Do not attempt telephone triage for suspected cardiac chest pain—direct immediate transport to ED. 3
• Be aware that elderly patients and those with diabetes may present with atypical symptoms despite severe disease. 2, 3

Non-Life-Threatening Causes (Lower Priority)

Once life-threatening causes are excluded through appropriate testing:

• Musculoskeletal: Chest wall tenderness on palpation, pain with inspiration or movement—these features markedly reduce ACS probability. 1
• Gastroesophageal reflux disease: Can mimic cardiac pain but typically lacks associated diaphoresis or radiation pattern. 4, 5
• Costochondritis: Localized tenderness at costochondral joints. 1
• Anxiety/panic disorder: May present with crushing chest pain but typically in younger patients without cardiac risk factors. 1, 5

The key principle: crushing chest pain with intact peripheral pulses most commonly represents ACS, which can have an entirely normal physical examination in uncomplicated cases, making ECG and troponin measurement essential for diagnosis. 1