Acute Coronary Syndrome Differential Diagnoses

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
  • Print

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. 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. [16]

Differential Diagnoses