The Importance Of Recognizing Atypical Presentations Of Acute Coronary Syndrome

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The classic presentation of an acute coronary syndrome (ACS) is that of an older age male smoker with hypertension reports exertional chest pressure that radiates to the left upper extremity he and his associated with shortness of breath. This presentation is well recognized by the emergency provider.

Unfortunately, many patients with ACS lack overt chest pain or pressure and present to the emergency room with “atypical” signs and symptoms. As a result, the emergency provider may fail to consider the diagnosis of acute coronary syndrome, leading to a greater risk of serious injury or patient death.

Recent literature has demonstrated that patients with atypical ACS presentations are less likely to receive anti-ischemic therapy and are more likely to die when compared to patients who present to the ER with the classic ACS presentation. Currently, more than 20% of ACS patients who present with atypical signs and symptoms are missed upon initial evaluation. In order to prevent unnecessary injury and death, it is critical for the emergency provider to identify patients with ACS who did not present with textbook symptoms.

Common atypical ACS symptoms include:

  • dyspnea (shortness of breath)
  • diaphoresis (sweating)
  • nausea
  • vomiting
  • near syncope (temporary loss of consciousness)

Jaw pain, neck pain, back pain, extremity pain, abdominal pain, and fatigue or additional symptoms that can also be caused by an ACS. Due to the absence of chest pain with these symptoms, and electrocardiogram (EKG) and cardiac markers like troponins are often delayed or not obtained all together.

It is critical that emergency medicine practitioners be aware of that fact that patients with atypical ACS presentations are more likely to be female or elderly or have a history of diabetes or heart failure. Women are at particularly high risk for missed diagnosis of ACS. Not only are women more likely to have atypical presentations, they are also more likely to have diabetes and be younger at the time of ACS presentation. In addition, women present later in the time course of their illness when compared to ACS patients your present with the classic symptom of chest pain.

Patients with diabetes have long been recognized to present with atypical features of ACS. This higher rate of a typical ACS presentation is thought to be due to a neuropathy that affects the sensory innervation to the heart.

Finally, patients with atypical ACS presentations are less likely to have a history of smoking, hyperlipidemia, or prior cardiac disease. Importantly, concern for ACS should not solely be limited to female, diabetic, or older patients who present with atypical symptoms. ACS should be considered for any symptoms without any obvious cause that could potentially be caused by cardiac ischemia.

The most important step in making the diagnosis of ACS is to simply consider the diagnosis and patients presenting with the symptoms listed above. Medical practitioners must obtain an EKG in any patient that raises a clinical concern for ACS. If the EKG is non-diagnostic, it is prudent to obtain cardiac markers like troponins and placing patients in observation for additional diagnostic testing. Furthermore, it is important to administer time-sensitive therapy when the diagnosis of ACS is considered. This may include antiplatelet or anticoagulant medications, along with cardiology consultation.

A failure to follow these steps combined with poor patient outcome may be evidence of medical malpractice – even if the ACS symptoms are “atypical.”

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