Estudiante

Cardiol Clin 24 (2006) 1–17

Initial Approach to the Patient who has Chest Pain
Luis H. Haro, MDa,b,*, Wyatt W. Decker, MDa,b, Eric T. Boie, MDa,b, R. Scott Wright, MDa,c
a Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA c Division of Cardiology and Cardiac CoronaryUnit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA b

Scope of the problem According to Center for Disease Control 2001– 2002 National Hospital Ambulatory Medical Care Survey, an estimated 107 to 110 million visits were made to hospital emergency departments. Of these, approximately 3.5 to 5.4 million visits (3.4% to 5.3%) were patients who presented with chest pain as their chiefcomplaint [1]. In 2001, first-listed and secondary hospital discharge data from the National Registry of Myocardial Infarction-4 (NRMI-4) indicate there were 1,680,000 unique discharges for acute coronary syndrome (ACS) [2]. In evaluating acute chest pain, the immediate goal is to determine the accurate diagnosis and to initiate the appropriate life-saving therapies as quickly as possible. It isparticularly important to identify as quickly as possible those patients presenting with ST-segment elevation myocardial infarction (STEMI) so that the appropriate reperfusion therapies can be initiated with as little delay as possible. Recent work estimates that at least 500,000 patients each year qualify for acute reperfusion therapy for STEMI [3]. The particular challenge facing today’s practitionersof emergency medicine is to evaluate every patient who presents with acute chest pain for a variety of life-threatening causes of chest pain, such as ACS, acute aortic dissection (AD), pulmonary embolism (PE), pericardial disease with

tamponade physiology, penetrating ulcer, and tension pneumothorax (Box 1). Once these entities are excluded, other benign causes of chest pain are considered.Most of the cases presenting with acute chest pain are of benign origin. This article focuses on assessment; diagnosis, and management within the first 2 to 3 hours of emergency department presentation of patients who have a chief complain of chest pain and whose clinical status or diagnosis merits admission to the coronary care unit or medical ICU. Prehospital evaluation and interventions A patientcomplaining of chest pain who is at risk for ACS should be transported from home or the outpatient clinic to the emergency department by an ambulance with advanced life-support (ALS) capabilities. Only ALS ambulance personnel can obtain intravenous access, provide sublingual nitroglycerin and morphine, and provide advanced cardiac life support if the patient’s condition deteriorates in route.Advanced emergency medical services (EMS) can also perform and transmit prehospital ECGs (PH-ECGs), stabilize a compromised airway including endotracheal intubation and initiation of mechanical ventilation, and initiate pharmacologic support in situations of hemodynamic compromise before arrival at the emergency department. Many patients who have acute myocardial infarction (AMI) suffer cardiac arrestin the first few hours of the event. Many of these patients die at home suddenly. The use of an ALS-based EMS offers the best option for early, rapid management of cardiac arrhythmias and sudden cardiac death. Lives are saved by having excellent prehospital
cardiology.theclinics.com

* Corresponding author. Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.E-mail address: haro.luis@mayo.edu (L.H. Haro).

0733-8651/06/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ccl.2005.09.007

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Box 1. Differential diagnosis of chest pain Life-threatening causes Acute coronary syndrome Aortic dissection Pulmonary embolus Tension pneumothorax Other cardiovascular and nonischemic causes Pericarditis Atypical...