Diagnosis Wikidoc: Chest Pain no ST elevation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

There are 4 other Life Threatening Diseases to Exclude Immediately:

1. Aortic Dissection

Supportive symptoms and signs include the following:
- Back pain in 67% of cases
- Diminution or absence of pulses in 40% of case
- Coma, altered mental status, Cerebrovascular accident (CVA) and vagal episodes are seen in up to 20%
- Descending dissection can lead to splanchnic ischemia, renal insufficiency, lower extremity ischemia or pulse deficits or focal neurologic deficits due to spinal cord ischemia.
Chest X-Ray Abnormalities Include:
- An increased aortic diameter is the most common CXR finding, seen in up to 84% of patients.
- A widened mediastinum is the next most common finding, seen in 15-20%.
- Normal in 17%.
- Pleural effusion (hemothorax) in the absence of CHF can also be another clue to dissection.
Next Study to Do:
- MRI is currently thought to be the most sensitive noninvasive method of making the diagnosis of aortic dissection. As with CT, the diagnosis is made upon visualization of a double lumen with a visible flap. Sensitivity and specificity are both thought to be 98%, and the site of entry can be visualized in 85% of cases.

Supportive symptoms include:
- Shortness of breath
- Chest pain
- Dyspnea
- Anxiety
- Pleuritic chest pain
Supportive laboratory studies include:
- D-dimers are formed by the degradation of fibrin clot.
- Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer.
- Many other processes, such as pneumonia, congestive heart failure (CHF), myocardial infarction (MI), malignancy, and surgery, are also associated with a mild degree of fibrinolysis, and hence an elevated D-dimer is not specific for pulmonary embolism.
- Its negative predictive value, however, is 91 – 94%

Next study to do:
- Spiral CT scanning is now a standard modality to non-invasively diagnose PE.
- Initial studies reported sensitivities for diagnosing emboli to the segmental level (4th order branch) as high as 98%

Supportive signs and symptoms include:
- The classic Meckler’s triad of symptoms includes vomiting, lower chest pain, and cervical subcutaneous emphysema following overindulgence in food or alcohol, but is observed in only half of the cases.
- The most common chest radiograph findings in spontaneous esophageal rupture (SER) are pleural effusion (91%) and pneumothorax (80%).
- The initial sign on a plain film may be pneumomediastinum or subcutaneous emphysema.
- Up to 12% of patients with SER may have a normal chest radiograph.
Next study to do:
- Contrast-enhanced esophageal radiography is diagnostic in 75% to 85% of cases.