Chapter 15
Chest Pains and Angina
1. Are most emergency room (ER) visits for chest pain caused by acute coronary syndromes (ACS)?
2. What are the other important causes of chest pains besides chronic stable angina and ACS?
The differential diagnosis for chest pains include the following:
Coronary artery spasm (Prinzmetal angina, cocaine abuse)
Musculoskeletal pain and cervical radiculopathies (costochondritis)
Gastrointestinal (GI) causes (reflux, esophagitis, esophageal spasm, peptic ulcer disease, gallbladder disease, and esophageal rupture [Boerhaave syndrome])
3. Does an elevated troponin level make the diagnosis ACS?
Not necessarily. Although troponin elevations are fairly sensitive and specific for myocardial necrosis, it is well known that other conditions can also be associated with elevations in cardiac troponins. Importantly, troponin elevation can occur with pulmonary embolus and is in fact associated with a worse prognosis in cases of pulmonary embolus in which the troponin levels are elevated. Myopericarditis (inflammation of the myocardium and pericardium) may also cause elevated troponin levels. In addition, aortic dissection that involves the right coronary artery may lead to secondary MI. Further, troponins may be modestly chronically elevated in patients with severe chronic kidney disease. Troponin elevation has also been noted in patients with acute stroke. Studies to delineate the etiology of this are ongoing.
5. What are the associated symptoms that persons with angina may experience in addition to chest discomfort?
Radiating pains. Patients may describe pains or discomfort that radiate to the back (typically midscapula), the neck, the jaw, or down one or both arms. They may also describe a numbness-type sensation in the arm.
6. What are the major risk factors for CAD?
Sex. Males are at higher risk of developing CAD, particularly earlier in life.
Family history of premature CAD. This is traditionally defined as a father, mother, brother, or sister who first developed clinical CAD at age younger than 45 to 55 years for men and at age younger than 55 to 60 years for women.