Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis (50 page)

   Individuals with no clear cardiovascular or pulmonary etiology of symptoms

   Isolated chest wall syndromes: Costochondritis (no swelling, point tenderness), Tietze syndrome (young adults with swelling at second or third rib), sternalis (palpation causes bilateral radiation of pain), xiphoidalgia, sternoclavicular subluxation (usually dominant side, often in middle-aged women), fractures, and chest wall syndrome due to herniated disc

   Systemic chest pain syndromes: fibromyalgia, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and sickle cell disease/crisis

   Laboratory and Imaging

   Diagnostic approach should first exclude cardiac, pulmonary, and abdominal etiologies either by exam or by focused testing. Older patients should receive ECG, CBC, urinalysis, and chest radiograph given the higher likelihood of atypical presentation of ACS and infectious processes.

   Exclusion of a systemic rheumatic process should be performed. ESR is a nonspecific test for inflammatory conditions. The presence of back stiffness should be evaluated with lower-back radiographs and HLA-B27 antigen to assess for spondyloarthropathies.

   Psychogenic/Psychosomatic

Several large registries have identified up to one third of patients presenting to emergency departments with chest pain have a psychiatric disorder. Panic disorder is a particularly common diagnosis, although appropriate clinical and laboratory evaluation for organic disease must be performed before symptoms are attributed to psychiatric disorders. Hyperventilation may cause ST and T-wave changes on ECG and result in nonanginal chest pain. Furthermore, elevations of heart rate and blood pressure may precipitate true ischemia in individuals with preexisting coronary atherosclerosis.

Suggested Readings

Evans DW, Lum LC. Hyperventilation: an important cause of pseudoangina.
Lancet.
1977;1:155.

Wuslin LR, Yingling K. Psychiatric aspects of chest pain in the emergency department.
Med Clin North Am.
1991;75:1175.

DYSPNEA

As dyspnea is a nonspecific presenting symptom for a number of clinical syndromes, the selective use of diagnostic testing and laboratory assessment can aid in the differentiation of cardiac from noncardiac etiologies. Most common cardiac etiologies include CAD, congestive heart failure (CHF), valvular disease, and arrhythmia. Individuals with a moderate coronary risk profile who report exertional symptoms should undergo appropriate risk stratification (see stress testing above). Over the past several decades, the prevalence and incidence of congestive heart failure have increased dramatically with CHF now accounting for the largest cost of Medicare. Diagnostic testing is an important adjunct to the clinical diagnosis of CHF to help identify reversible etiologies or precipitants, monitor treatment response, aid in prognosis, and screen for potential heritable conditions.

CONGESTIVE HEART FAILURE

   Definition

   Heart failure (HF) is the inability of the cardiac output to meet the metabolic demands of the body due to an impaired ability of the ventricle to fill or eject blood. It is a clinical syndrome that occurs at the end stage of a number of structural or functional cardiac disorders.

   The nonspecific symptoms of HF are due to either excess fluid accumulation (dyspnea, orthopnea, ascites, edema) or poor cardiac output (fatigue, weakness) either with exertion, or, when severe, at rest.