By Jennifer Kearney-Strouse
When you're working up an outpatient with chest pain, when do you call 911? At a Thursday morning session, Renee Bullock-Palmer, MD, offered internal medicine physicians a range of red flags to watch for.
The first clinical indicator is pain at rest, especially if it lasts for more than 10 to 20 minutes, Dr. Bullock-Palmer said, adding some additional risk factors. “If there's any hemodynamic instability, hypotension, S3 gallop, new pulmonary edema, that might be someone that is in acute flash pulmonary edema," she said. “That patient should go directly to the ER.”
If you do an electrocardiogram in the office and find dynamic ST changes, especially ST elevation, that's another bona fide emergency.
“You want to have those patients going to the cath lab,” said Dr. Bullock-Palmer, who is the director of noninvasive cardiac imaging, director of nuclear cardiology, and director of the Women's Heart Center at Deborah Heart and Lung Center in Browns Mills, N.J. “Time is [heart] muscle, so get those patients to the local ER as soon as possible.”
She also advised attendees to avoid what she called the “troponin trap.” “If you suspect acute coronary syndrome, do not wait for office-based labs. Those patients should go straight to the ER [to] get their serial troponins. Call the ER physician and get this patient in.”
Dr. Bullock-Palmer, who is also a clinical associate professor in the division of cardiology at Thomas Jefferson University in Philadelphia, addressed the misconception that women don't present with chest pain as often as men. “That's actually not true," she said. “We do present as equally as men with chest pain, but oftentimes it's buried in a whole conglomerate of other symptoms, like dyspnea, profound fatigue, epigastric pain, back pain, so really try to sort this out with the history.”
She suggested asking patients not whether they have chest pain but rather if they have any sensation in the chest. “You'll be surprised, patients will say, ‘No, I do not have chest pain. I have chest pressure,’ which, of course, is a red flag.”
For patients who are elderly, especially over age 75 years, remember that sometimes they may not present with chest pain, even when the problem is the heart, Dr. Bullock-Palmer said. “The family members may say … ‘Grandma is just not looking right, she's short of breath, she's less aware.’ And sometimes there might even be delirium, so for those patients, you might want to have a higher level of suspicion, and it's better to err on the side of caution and … rule out a coronary or cardiac cause.”
She also noted that unexplained falls in elderly patients can herald a cardiac event. “Make sure you find out, did the patient pass out that led to the fall? Because that could be syncope that they're misinterpreting as a simple fall.”
Other red flags that are clinical indicators for emergency transfer include crescendo angina. “If you have had increasing frequency of the chest pain, duration of chest pain, especially if it's within the last four weeks, occurring with progressively less exertion, that's the definition of crescendo angina,” she said.
New chest pain in a patient with a very recent history of myocardial infarction or percutaneous coronary intervention is also an urgent indicator, especially if it's similar the pain that led to a bypass or stent in the first place, Dr. Bullock-Palmer noted.
Symptoms to worry about in patients with chest pain include acute dyspnea, which is suggestive of flash pulmonary edema or anginal equivalent. Similarly, presyncope or syncope may indicate life-threatening arrhythmia or critical aortic stenosis.
“If you have someone that's presyncope or has had syncope, and you hear a very loud systolic murmur suggestive of aortic stenosis, then those patients really should be acutely evaluated,” she said. She noted that diaphoresis and nausea are autonomic symptoms that are often associated with transmural ischemia.
On physical exam, look out for hypotension, Dr. Bullock-Palmer said, defining this as a systolic blood pressure of less than 90 mm Hg or a significant drop from baseline, “especially if the patient is diaphoretic, cyanotic.”
Final red flags on her list included unequal pulses, which could indicate aortic dissection, and new murmurs. Specifically, a new holosystolic murmur could signal papillary muscle dysfunction due to inferior lateral infarct with rupture leading to severe ventricular septal defect. “Oftentimes these patients are very sick, and they have to go to the emergency room to be admitted,” she said. “If there are rales on examination or S3 gallop, that's an indicator for acute heart failure as well.” ■