Emergency Medicine

CHEST PAIN

48 General Medical Emergencies

NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTEMI) AND

UNSTABLE ANGINA

DIAGNOSIS

1 The predisposing factors and pathophysiology are the same as for STEMI

(see p. 4 4).

2 It is not possible from the character of the chest pain alone to accurately

exclude ACS, unless a clear alternative cause for the pain is apparent (see

Table 2.1).

Table 2.1 Differential diagnosis of chest pain in patients presenting with possible

acute coronary syndrome (ACS)

Diagnosis Classic history Physical

examination

Diagnostic

testing

Acute coronary

syndrome

(see p. 44)

Band-like, tight, or

pressure pain with

radiation to neck and

arms, sweating,

dyspnoea, cardiac risk

factors

May be normal, or

may have evidence

of heart failure,

hypotension

Cardiac

biomarkers,

ECG,

possibly stress

testing

Pulmonary

embolus

(see p. 51)

Sudden onset, pleuritic

pain, dyspnoea,

risks for venous

thrombo-embolism

Tachycardia,

tachypnoea, pleural

rub, low-grade

fever

CXR, V/Q scan,

CTPA

Aortic

dissection

(see p. 57)

Sudden, sharp, tearing

pain radiating to back,

neurologic symptoms

Unequal pulses or

BP, new murmur,

bruits

CXR,

echocardiogram,

CT angiogram

Pericarditis

(see p. 58)

Pleuritic, positional

ache, worse lying

down

Fever, pericardial

rub, tachycardia

ECG, CXR,

echocardiogram

Pneumonia

(see p. 67)

Cough, fever,

dyspnoea, pleuritic

pain, malaise

Fever, hypoxia,

tachypnoea,

tachycardia,

abnormal breath

sounds

CXR, WCC

Pneumothorax

(see p. 72)

Pleuritic pain,

dyspnoea

Reduced breath

sounds over

hemithorax

CXR

Oesophageal

rupture

(Boerhaave’s

syndrome)

(see p. 236)

Constant, severe

retrosternal pain,

dysphagia

Subcutaneous

emphysema

CXR, CT chest