Inappropriate reliance on nondiagnostic maneuversģ. However, when the actress reported the same complaint in a "histrionic" manner, only 13% believed that she had a cardiac condition.Ī history of a psychiatric diagnosis or overwhelming anxiety in a patient with acute chest pain does not preclude the possibility of an acute coronary event. Half of the physicians who reviewed the tape believed that the patient had a cardiac condition. Birdwell and colleagues 5 demonstrated this bias when they videotaped an actress portraying a patient who described her chest pain in a "businesslike" manner. A new patient with chest pain whose medication list includes numerous psychiatric drugs may be more likely to have his or her complaints dismissed as psychiatric. The appearance and mannerisms of a patient with chest pain may profoundly influence a physician's approach. Making a disposition decision based on the patient's psychiatric history or level of anxietyĢ. Table 2 – Intensity of pain according to the modified visual analog scale 4 Pain that radiates to the throat, back, or epigastrium may be cardiac in origin and should not automatically be attributed to esophageal or aortic causes. However, chest pain that radiates to the right shoulder is more specific for pain of cardiac origin than pain that radiates to the left shoulder. Pain that radiates to the left arm and shoulder is often assumed to indicate coronary ischemia, whereas pain that radiates to the right shoulder is thought to suggest a biliary source. The pattern of chest pain radiation may also be a source of confusion. 2 However, 33% of patients with AMI report no chest pain. The intensity of chest pain, usually assumed to be significant in AMI, may be rated from 0 to 10 on the 10-point pain scale ( Table 2). 1 Consequently, women-as well as persons with diabetes and elderly persons-who have an AMI are more likely not to experience chest pain, or to have nonspecific complaints such as dyspnea, nausea and vomiting, unusual fatigue or weakness, palpitations, or presyncope. This may be explained in part by the fact that women are usually older and have more comorbidities (such as hypertension, diabetes, and heart failure) than men at presentation. Moreover, women who have AMI present with atypical symptoms more frequently than do men. Table 1 – Descriptors of pain in patients with and without confirmed AMIįrom Hofgren C et al. However, only 50% of patients with AMI describe their pain in classic terms such as "crushing" or "pressure-like." Many alternative descriptors of chest pain are used, the most frequent of which include aching, cramping, and grinding ( Table 1). Crushing retrosternal pain or pressure suggests a cardiac source of chest symptoms. Atypical presentations in the quality, intensity, and radiation of pain are common in patients with ACS. Failure to recognize atypical clinical presentations of acute coronary syndrome (ACS)ġ. Our goal is to expose these misconceptions thus, we review here the 10 most common mistakes made in the evaluation. The evaluation of patients with acute chest pain has been hindered by the widespread promulgation of myths that can result in the delay of care or even harm. Conversely, discharging a patient with an acute myocardial infarction (AMI) can be disastrous. A practice of "admitting everyone" with such symptoms places an excessive burden on financial and acute care resources. The decision to admit or discharge a patient with acute chest pain can have significant consequences. About 6 million patients present to emergency departments (EDs) in the United States each year with acute chest pain.
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