Ten Pearls regarding Coronary Artry Symptoms and Chest pain.

1- Many patiensts with acute coronary symptoms do not have classic text  book symptoms. Crushing chest pain may indicate a heart attack in one patient, whereas mild shortness of breath may indicate the same disease process in another. With age progresses, chest pain declines in frequency as the presenting symptom however breathlessness, syncopy or stroke become more common. Pain in epigastric area, back, jaw pain, heart burn is more common among women as compared to men. Remember to keep in mind, that heart attack symptoms may be atypical like nause vomiting indigestion feeling or may be abcent especially in women, diabetics and elderly.

2- Angina does not always mean coronary artry diseas. Left Ventricular out flow track obstruction like aortic stenosis or hypertrophic obstructive cardiomyopathy can also cause classic angina as may anemia.

3-Features which make coronary pain unlikely include stabbing pains, pain lasting less than 30 seconds, localized left inflammatory pain and having continually varing location.

4- Patienst may use the word sharp to convey severity of pain rather than as a description of the character of pain.

5-Don't always assume that change in chest pain represents unstable angina, nitroglycerine may have lost their potency. Check for associated symptoms of headache stinging and flushing. Some patients may also be non compliant with their medications.

6- A high index of suspicion is necessary to avoid missing the diagnosis of acute aortic dissection or pericarditis. This distinction from acute Myocardial infarction is essential, scisnce thrombolytic therapy is contraindicated in these conditions.

7-Ongoing chest pain that has been present for an extended period of timemay still represent angina. Further questioning of the patient may reveal that the pain is actually intermittent scince its onset and not constant.

8-Don't attibute cardiac symptoms to other chronic underlying conditions, e.g hiatal hernia or esophageal spasm. A history of such an underlying disease does not rule out a new cardiac condition.

9- Not all patients with acute MI develop ECG changes. As many as 1/3 do not develop any changes at al.Because ECG changes are not always seen with acute MI and serum markers may take time to evolve, the key determinant wheather or not to hospitalize a patient with chest pain remains the clinical history.

10-Although risk factors for coronary artry disease are important to keep in mind when evaluating a patient with chest pain, a significant percentage of patients presenting with acute myocardial infarction may have no risk factors.

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