Symptoms of Acute Coronary Syndromes (ACS)
The classic symptom of ACS is chest discomfort, but patients frequently present with additional symptoms including shortness of breath, diaphoresis (sweating), nausea, vomiting, dizziness, and pain radiating to the upper body (neck, jaw, shoulders, back, or arms). 1
Primary Symptoms
- Chest discomfort is the predominant presenting symptom, typically described as central/substernal compression, crushing, pressure, tightness, heaviness, cramping, burning, or aching sensation 2
- Dyspnea (shortness of breath) commonly accompanies chest discomfort as a primary symptom 1
- Diaphoresis (cold sweat) is a key associated symptom that should raise suspicion for ACS 1, 2
- Pain radiation to the neck, jaw, shoulders, back, or one or both arms is characteristic 2
Additional Symptoms
- Nausea and vomiting frequently occur alongside chest discomfort 1, 2
- Dizziness or lightheadedness may be present 1
- Palpitations can occur, particularly in women 2
- Unexplained indigestion, belching, or epigastric pain should raise concern for cardiac ischemia 2
Critical Timing
Symptoms typically persist for longer than 15-20 minutes, distinguishing ACS from stable angina. 1 When symptoms are unremitting for more than 20 minutes, the possibility of myocardial infarction must be strongly considered, and immediate assessment with 12-lead ECG is essential 1
Atypical Presentations (High-Risk Groups)
Women
- Women may present with nausea, back pain, dizziness, and palpitations in addition to or instead of classic chest pain 2
- Women are often 8-10 years older than men when presenting with ACS and have higher prevalence of traditional risk factors 2
- Atypical symptoms are more common in women, and they are less likely to receive timely appropriate care 1, 2
Elderly Patients
- May present with generalized weakness, stroke, syncope, or changes in mental status rather than classic chest symptoms 1, 2
- Atypical symptoms are significantly more frequent in this population 1
Diabetic Patients
- May have atypical presentations due to autonomic dysfunction 1, 2
- Diabetes is a stronger risk factor for ACS in women than in men 2
Important Clinical Pitfalls
- The chest discomfort is usually NOT dramatic like the "Hollywood heart attack" portrayed in media 1
- Relief with nitroglycerin is NOT diagnostic of myocardial ischemia and should not be used as a diagnostic criterion 2
- Isolated diaphoresis, nausea, vomiting, or dizziness are unusual as predominant presenting symptoms but can occur 1
- Physical examination is often normal in patients with ACS 1
High-Risk Features Requiring Immediate ED Referral
Patients with the following features should be referred immediately to the emergency department and transported by EMS: 1
- Continuing chest pain or ischemic symptoms at rest for more than 20 minutes 1
- Severe dyspnea 1
- Hemodynamic instability 1
- Syncope or presyncope 1
- Palpitations 1
Initial Action for Patients
Patients should immediately call 9-1-1 when experiencing symptoms suggestive of ACS rather than self-medicating or delaying. 1 Taking aspirin should not delay calling EMS, as emergency dispatchers can provide instructions to chew aspirin (162-325 mg) while personnel are en route 1