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Clinical Scenario: Differentiating Ischemic Chest Discomfort in a Patient

Patient Presentation:

Mr. Smith, a 58-year-old male, presents to the emergency department complaining of chest discomfort.

He describes the sensation as “strangling and anxiety” and notes that it feels like an aching, heavy, squeezing, crushing, or constricting pain in his chest.

The pain began gradually and has been intensifying over the past few minutes. He also mentions that the discomfort radiates down his left arm, making it feel numb, and occasionally experiences a burning sensation.

He denies any other symptoms such as shortness of breath, nausea, or diaphoresis.

Clinical Assessment:

  1. Characteristics of Chest Discomfort:

    • The patient’s chest discomfort is described as aching, heavy, squeezing, and crushing, consistent with myocardial ischemia.
    • Radiation of the pain down the ulnar surface of the left arm is noted.
    • The discomfort is located retrosternally.
    • The quality of discomfort varies from vague tightness to a burning sensation.
  2. Pattern and Duration of Symptoms:

    • The pain began gradually and reached its maximal intensity over a few minutes, which is typical for stable angina.
    • There is no relief with rest or nitroglycerin.
  3. Differential Diagnosis:

    • The patient’s presentation is suggestive of ischemic chest discomfort, but further evaluation is needed to determine whether it is stable angina, unstable angina, or a myocardial infarction (MI).
    • Stable angina is characterized by discomfort that occurs predictably with a characteristic level of exertion or psychological stress, which may not be the case here.
    • Unstable angina is characterized by chest discomfort that occurs with progressively lower levels of physical activity or even at rest.
    • MI is usually more severe, prolonged (lasting ≥30 minutes), and not relieved by rest.

Next Steps:

  1. Conduct a 12-lead ECG to evaluate for any acute ST-segment changes.
  2. Obtain cardiac biomarkers (troponin levels) to assess for myocardial injury.
  3. Initiate oxygen therapy, establish intravenous access, and administer aspirin and nitroglycerin as indicated.
  4. Consider other tests such as coronary angiography to further differentiate the cause of chest discomfort.


This clinical scenario highlights the importance of assessing the characteristics, pattern, and duration of chest discomfort in a patient to differentiate between stable angina, unstable angina, and myocardial infarction, ultimately guiding appropriate management and treatment decisions.

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Dr. Arin Nandi

Passionate About Medical Science & Helping Future Doctors Achieve Top Ranks In Medical Exams. He is professionally a dentist as well as a public health expert from JIPMER working in department