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4/6/2014 Acute Coronary Syndrome Differential Diagnoses

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Acute Coronary Syndrome Differential Diagnoses
Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD more...

Updated: Mar 12, 2014

Diagnostic Considerations
As many as half of all cases of ACS are clinically silent in that they do not cause the classic symptoms of this
syndrome. Consequently, ACS goes unrecognized by the patient. Maintain a high index of suspicion for ACS,
especially when evaluating women, patients with diabetes, older patients, patients with dementia, and those
with a history of heart failure.
Although ST-segment and T-wave changes are associated with CAD, alternative causes of these findings are
left ventricular aneurysm, pericarditis, Prinzmetal angina, early repolarization, Wolff-Parkinson-White
syndrome, and drug therapy (eg, with tricyclic antidepressants, phenothiazines).
Increasing public awareness of the typical and atypical presentations of ACS is of the utmost importance for
optimal and timely treatment. Many patients do not recognize that their symptoms are cardiac in origin and
therefore may delay seeking medical help. Guidelines from the European Society of Cardiology
(ESC)/American College of Cardiology (ACC)/American Heart Association (AHA) recommend that patients with
established CAD call emergency medical services if they have chest pain that does not resolve after they take
a sublingual nitroglycerin tablet.
In patients presenting to the ED with chest pain, a structured diagnostic approach that includes time-focused
ED decision points, brief observation, and selective application of early outpatient provocative testing appeared
both safe and diagnostically efficient in a study by Scheuermeyer et al. However, some patients with ACS may
be discharged for outpatient stress testing on the index ED visit.
[13]
Differential Diagnoses
Anxiety
Aortic Stenosis
Asthma
Cardiomyopathy, Dilated
Esophagitis
Gastroenteritis
Hypertensive Emergencies in Emergency Medicine
Myocardial Infarction
Myocarditis
Pericarditis and Cardiac Tamponade

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Discussion

Contributor Information and Disclosures
Author
David L Coven, MD, PhD Assistant Professor of Clinical Medicine, Columbia University College of Physicians
and Surgeons; Director, Cardiology Outpatient Clinic, St Luke's Site, Attending Physician, Department of
Medicine, Division of Cardiology, St Luke's-Roosevelt Hospital Center
4/6/2014 Acute Coronary Syndrome Differential Diagnoses
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David L Coven, MD, PhD is a member of the following medical societies: American College of Physicians,
American Medical Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.
Coauthor(s)
Arun Kalyanasundaram, MD, MPH Interventional Cardiology Fellow, Department of Cardiology, Cleveland
Clinic
Arun Kalyanasundaram, MD, MPH is a member of the following medical societies: American College of
Cardiology, American College of Physicians, American Heart Association, Society for Cardiac Angiography and
Interventions, Society of General Internal Medicine, Society of Hospital Medicine, and Southern Medical
Association
Disclosure: Nothing to disclose.
Jamshid Shirani, MD Director of Cardiology Fellowship Program, Director of Echocardiography Laboratory,
Director of Hypertrophic Cardiomyopathy Clinic, St Luke's University Health Network
Jamshid Shirani, MD is a member of the following medical societies: American Association for the
Advancement of Science, American College of Cardiology, American College of Physicians, American
Federation for Medical Research, American Heart Association, American Society of Echocardiography, and
Association of Subspecialty Professors
Disclosure: Nothing to disclose.
Chief Editor
Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catheterization Laboratory and
Interventional Cardiology, Mayo Clinic Arizona
Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.
Additional Contributors
Craig T Basson, MD, PhD Gladys and Roland Harriman Professor of Medicine, Director of the Center for
Molecular Cardiology, Director of Cardiovascular Research, Division of Cardiology, Department of Medicine,
Weill Cornell Medical College; Attending Physician, New York Presbyterian Hospital
Craig T Basson, MD, PhD is a member of the following medical societies: American College of Cardiology and
American Heart Association
Disclosure: Nothing to disclose.
Edward Bessman, MD, MBA Chairman and Clinical Director, Department of Emergency Medicine, John
Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins
University School of Medicine
Edward Bessman, MD, MBA is a member of the following medical societies: American Academy of Emergency
Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice
Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency
Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Steven J Compton, MD, FACC, FACP Director of Cardiac Electrophysiology, Alaska Heart Institute,
Providence and Alaska Regional Hospitals
4/6/2014 Acute Coronary Syndrome Differential Diagnoses
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Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical
Association, American College of Cardiology, American College of Physicians, American Heart Association,
American Medical Association, and Heart Rhythm Society
Disclosure: Nothing to disclose.
Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor,
Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians,
National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management
position; ProceduresConsult.com Royalty Other
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
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