angina equivalence، That is, when we speak of a coronary syndrome, we typically refer to the patient with the full constellation of signs and symptoms … and that is where we begin to have problems, especially when the patient’s only manifestation consists of chest pain equivalents.
The patient does not read the book.
The patient expresses what he feels, not necessarily what you want to hear. The fact that the patient does not describe all the signs and symptoms that you are accustomed to associate with a coronary syndrome, including chest pain, does not mean that you can rule out that it may be happening.
When a patient with chest pain has an uncommon manifestation, we say that he has an atypical picture.
Woman, diabetic and advanced age. This is the perfect formula for a silent heart attack. Patients with a silent heart attack do not complain of chest pain. They may complain of any of the other signs and / or symptoms, but they do not verbalize chest pain.
In the case of diabetic patients, the neuropathies they develop do not manifest pain as a symptom.
Atypical infarcts are more typical than we think.
The data suggests that infarcts that do not manifest typical signs, that is, atypical manifestations, are more common than we previously thought. Therefore, we have to learn to recognize that other signs may be just as important as traditional chest pain.
Equivalents of angina pectoris
The equivalents of chest pain are signs and symptoms that make us think of a coronary syndrome even when the patient does NOT have chest pain.
The chest pain equivalents can be each of the other typical signs of a myocardial infarction.
It is important to think about chest pain equivalents when questioning the patient about the possibility that their current condition is a coronary syndrome.
For example, you are evaluating an elderly patient, diabetic, with difficulty breathing, general weakness and nausea, with 184 mg / dL of glycemia, and with vital signs within normal values. Although you do not complain of chest pain, you should think that this may be an acute coronary syndrome, and you should immediately perform a 12-lead ECG to stratify the risk.
In another example, you are evaluating a 52-year-old patient who suffered syncope. The patient is alert, conscious and oriented. You are worried that you may be a coronary patient and decide to perform a 12-lead ECG. The ECG shows no changes in ischemia, but you know that the ECG may be normal and still have a coronary syndrome. You ask the patient if he has had chest pain, and he says no. But, he does say that he has had pain in his right arm and some difficulty in breathing since the event. Both could be considered as equivalent of chest pain in the appropriate context.
In these two examples, the patient has the stigma of a coronary patient, despite not presenting the main complaint of chest pain.
Pain anywhere else
The nerve fibers that receive information back to the central nervous system are divided into somatic or visceral. Somatic fibers innervate the skin and bones, for example. Somatic fibers connect in the central nervous system at specific points. This allows the brain to clearly conclude where the pain signal is coming from. It is easy for the patient with a fractured rib to specify which point on the chest is painful.
In contrast, visceral fibers connect in the central nervous system at multiple points. This means that sometimes the patient can not specify where the pain originates , or vice versa, manifesting the pain in another place instead of where it really originated. For example, pain from coronary ischemia may manifest as pain in the abdomen, back, neck, or jaw. All these are equivalent to chest pain.
As if that were not enough, signs such as general weakness and difficulty breathing can also be equivalent signs of chest pain in patients with coronary heart disease.
Medical history is not decisive
The medical history is important, but does not rule out the possibility that it is a coronary event. The fact that a patient has been previously evaluated for coronary disease does not rule out that he may have it.
Evaluation and patient management
The 12-lead EKG is the cornerstone in the diagnosis of acute coronary syndrome. It is important to remember that you are not doing the EKG exclusively because you believe that the patient is infarcting. You are doing it too when you can not rule out that the manifestation may be coronary. Therefore, the EKGs of patients with chest pain equivalents may reveal tremendous surprises when it is discovered that they indeed have changes in ischemia and / or infarction.
Learn more about how to evaluate and treat this patient in our ACLS course , which we offer at ECCtrainings every weekend in Puerto Rico. This course is certified by the American Heart Association.