Acute Chest Discomfort In patients with acute chest discomfort, the clinician must first assess the patient's respiratory and hemodynamic status. If either is compromised, initial management should focus on stabilizing the patient before the diagnostic evaluation is pursued. If, however, the patient does not require emergent interventions, then a focused history, physical examination, and laboratory evaluation should be performed to assess the patient's risk of life-threatening conditions. Clinicians who are seeing patients in the office setting should not assume that they do not have acute ischemic heart disease, even if the prevalence may be lower. Malpractice litigation related to myocardial infarctions. | Chapter 013. Chest Discomfort Part 6 Acute Chest Discomfort In patients with acute chest discomfort the clinician must first assess the patient s respiratory and hemodynamic status. If either is compromised initial management should focus on stabilizing the patient before the diagnostic evaluation is pursued. If however the patient does not require emergent interventions then a focused history physical examination and laboratory evaluation should be performed to assess the patient s risk of life-threatening conditions. Clinicians who are seeing patients in the office setting should not assume that they do not have acute ischemic heart disease even if the prevalence may be lower. Malpractice litigation related to myocardial infarctions that were missed during office evaluations is becoming increasingly common and ECGs were not performed in many such cases. The prevalence of high-risk patients seen in office settings may be increasing due to congestion in emergency departments. In either setting the history should include questions about the quality and location of the chest discomfort Table 13-2 . The patient should also be asked about the nature of onset of the pain and its duration. Myocardial ischemia is usually associated with a gradual intensification of symptoms over a period of minutes. Pain that is fleeting or that lasts hours without being associated with electrocardiographic changes is not likely to be ischemic in origin. Although the presence of risk factors for coronary artery disease may heighten concern for this diagnosis the absence of such risk factors does not lower the risk for myocardial ischemia enough to be used to justify a decision to discharge a patient. Wide radiation of chest pain increases probability that pain is due to myocardial infarction. Radiation of chest pain to the left arm is common with acute ischemic heart disease but radiation to the right arm is also highly consistent with this diagnosis. Figure 13-1 shows estimates derived .
