 |
I./4.5.: Differential diagnosis
As for differential diagnosis, other life-threatening and non-life-threatening diseases associated with intense chest pain should be thought of.
I./4.5.1.: Pulmonary embolism
It is characterized by an also sudden onset and intense pain, however in a typical case the nature of the pain is significantly different, it is lancinating, sharp; it is associated with breathing and accompanied by dyspnea, possibly hemoptysis. In severe cases a shock may develop or circulatory collapse may occur in the most severe cases. Physical examination may reveal a potential source of embolism in the lower extremity as a swollen leg, often not reported or not recognized by the patient. Typical (but not diagnostic) sign on the ECG is SI-QIII, i.e. formation of an S wave in lead I, as well as a Q and a negative T wave in lead III.
Strain of the right ventricle is suggested by negative T waves in leads V 2 to 4. In typical cases the suspicion is confirmed by the arterial blood gas values (hypoxia and hypocapnia), as well as D-dimer positivity. (The possibility of pulmonary embolism is practically excluded by a negative D-dimer examination). A diagnosis can be obtained by transesophageal echocardiography, or mostly by pulmonary CT angiography. (Theoretically the simultaneous performance of ventilation and perfusion scintigraphy is also diagnostic, but its availability is limited, and the CT angiography is faster).
I./4.5.2.: Aortic dissection
It may begin with a retrosternal chest pain similar to that of myocardial infarction; mostly this is very intense, unbearable. If it extends to the coronary orifices, it may also cause a real infarction with a picture of ST elevation on ECG. Characteristically the pain may migrate as the dissection progresses; the initially retrosternal pain is later felt by the patient in his/her neck and then in his/her back. It is diagnosed by transesophageal echocardiography, but mostly by CT angiography.
|
 |
In equivocal cases when a patient presents himself/herself with intense chest pain, and the ECG is not diagnostic for an ST-elevation myocardial infarction, up-to-date CT angiography, examination of the coronary may have a special importance as it may be diagnostic for all three diagnoses as a „triple-rule-out” examination.
After having excluded the above diseases, others (pericarditis, PTX, pleuritis, reflux disease, cholelithiasis etc.) should be thought of.
|
|