A 52-year-old man is evaluated in the office for chest discomfort. Over the past week, the patient has had a burning sensation in the center of his chest after eating heavy meals and when walking fast. He also gets "winded" easily. This morning he had the same discomfort that persisted for 30 minutes while he was sitting on the couch. The patient has not seen a physician for 5 years. His wife says that he snores loudly in his sleep. The patient has a 15-pack-year smoking history and quit 2 years ago. He drinks 2 or 3 beers on the weekends. Blood pressure is 152/90 mm Hg and pulse is 92/min and regular. BMI is 34 kg/m2. Heart and lung examinations are unremarkable. ECG is unremarkable. Which of the following is the most likely diagnosis in this patient?
Acute coronary syndromes | ||
Primary diagnostic finding | Management | |
STEMI | ST-segment elevation in ≥2 contiguous ECG leads | Emergency reperfusion (eg, PCI) |
Non-STEMI | Troponin elevation* | Medical management initially, reperfusion within 24 hr |
Unstable angina | Consistent history (eg, rest angina)** | |
*ECG shows nonspecific ischemic changes but no ST-segment elevation. **ECG shows nonspecific changes & troponin is not elevated. PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. | ||
This patient's dyspnea and burning sensation in the chest with exertion in the setting of multiple risk factors for coronary artery disease (eg, obesity, smoking history, likely undiagnosed hypertension) raise suspicion for stable angina, or myocardial ischemia that reproducibly occurs with an increase in myocardial oxygen demand. The fact that the same burning sensation occurs with minimal exertion (ie, after eating heavy meals) and now at rest raises concern for unstable angina, or angina resulting from obstruction of myocardial oxygen supply (eg, atherosclerotic plaque rupture, critical atherosclerotic stenosis).
Unstable angina is the least common type of acute coronary syndrome. The diagnosis is based on a history alone of rest angina or rapidly worsening stable angina symptoms. By definition, troponin levels are not elevated and ECG is unremarkable or reveals only nonspecific findings (eg, T wave abnormalities).
Although the myocardial ischemia is not sustained enough to cause a detectable serum troponin elevation, unstable angina signifies a poor short-term prognosis, and prompt intervention is warranted. The management of unstable angina is the same as that of non-ST-segment elevation myocardial infarction.
(Choice A) Cor pulmonale is right ventricular failure that results from a disease process in the lungs that leads to pulmonary hypertension, usually presenting with pitting lower extremity edema, hepatomegaly, and jugular venous distension. Hypoxic pulmonary vasoconstriction due to severe chronic obstructive pulmonary disease (COPD) or obstructive sleep apnea (OSA) are common causes. This patient's smoking history puts him at risk for COPD, and his snoring and elevated BMI raise suspicion for OSA, but he does not have significant signs of right ventricular failure.
(Choices B and C) Esophageal spasm presents with dysphagia to solids and liquids that is often associated with retrosternal chest pain and/or reflux symptoms (eg, heartburn, regurgitation). Hiatal hernia is usually asymptomatic, but it may cause reflux symptoms when large. These diagnoses would not explain this patient's dyspnea or chest discomfort elicited by mild exertion or now occurring at rest.
(Choice D) Pulmonary embolism typically presents with pleuritic chest pain and dyspnea. It would not explain a recurrent burning sensation in the chest and is less likely in the absence of tachycardia.
Educational objective:
Unstable angina is the least common type of acute coronary syndrome. It is diagnosed based on a history alone of rest angina or rapidly worsening stable angina symptoms. Unstable angina has a poor prognosis and warrants the same prompt management as non–ST-segment elevation myocardial infarction.