Unstable angina / non ST elevation myocardial infarction physical examination


 * Associate Editors-In-Chief:

Overview
Patients with suspected ACS must be evaluated rapidly. The objectives of the initial evaluation are first to identify signs of immediate life-threatening instability and then to ensure that the patient is moved rapidly to the most appropriate setting for the level of care needed based on diagnostic criteria and an estimation of the need for intervention. It is recommended that patients with a suspected ACS with chest discomfort or other ischemic symptoms at rest for more than 20 min, hemodynamic instability, or recent syncope or presyncope to be referred immediately to an ED or a specialized chest pain unit.

Physical Examination
Vital signs and appearance are two of the most important aspects of the physical exam. These two components of the physical exam can be assessed quickly and allow for immediate stratification into patients at higher or lower risk for death or nonfatal myocardial infarction.

Vital Signs
In the evaluation of a patient presenting with ACS hypotension (systolic blood pressure <100 mm Hg), tachycardia (pulse >100) and bradycardia (pulse <60 bpm) indicate that a patient is at higher risk.

As with the assessment of all patients, other abnormal vital signs such as hypoxia, tachypnea (RR >19), hypothermia (T <95 F) or fever (T >100.3 F) should raise concern, although they are not specifically suggestive of ACS.

If aortic dissection is considered in the differential diagnosis, blood pressure should be checked in both arms (>20 mm Hg differential is suggestive of aortic dissection).

Appearance of the Patient
A patient who appears anxious, diaphoretic, with pale skin and who is in obvious respiratory distress should demand immediate attention.

Eyes
The eye exam is typically not the focus of a physical exam for ACS, however, details such as pale conjunctiva (suggestive of anemia), exopthalmos (suggestive of hyperthyroidism), or cotton-wool spots (suggestive of hypertension), or retinopathy (suggestive of diabetes) on fundoscopic exam should be noted as they may allow for the identification of potential precipitants of or risk factors for myocardial ischemia.

Ear Nose and Throat
The ears and nose are typically not the focus of a physical exam for ACS. However, the examination of the buccal mucosa can help to determine a patient's volume status, as can the examination of the right internal jugular vein pulsations (JVP). A JVP which is elevated greater than 4 cm above the sternal angle (9 cm above the right atrium) is considered elevated and reflects elevated right atrial pressure.

Heart
The cardiac exam should evaluate for signs of cardiac failure, such as a 3rd heart sound ("gallop," from early diastolic filling from left ventricular systolic failure), a 4th heart sound ("gallop," from late diastolic filling from a stiff left ventricle, as from diastolic heart failure) or a new / increased systolic murmur of mitral regurgitation (as from papillary muscle rupture). The presence of a pericardial rub would suggest pericarditis instead of ACS.

Lungs
Bibasilar rales are suggestive of congestive heart failure and pulmonary edema. However, the absence of adventitious lung sounds does not preclude diastolic heart failure.

Abdomen
The abdominal exam is typically not the focus of a physical exam for ACS. However, a finding of a expansile, pulsatile mass in the upper abdomen suggests an aortic aneurysm and requires further urgent evaluation.

Extremities
Assess the lower extremities for edema, suggestive of heart failure. It is also important to palpate the radial, femoral and pedal pulses. Unequal radial pulses are suggestive of aortic dissection. Weak pedal pulses are suggestive of peripheral vascular disease. Femoral pulses are important to document in the event that cardiac catheterization is necessary.

Neurologic
The neurological examination is typically not the focus of a physical exam for ACS. However, mental status at the time of the initial assessment should be documented for future reference, should the patient's mental status deteriorate during the period of observation. Also, headache in the context of chest pain and severe hypertension (i.e., SBP > 210 mm/Hg or a DBP > 120 mm/Hg) would support a diagnosis of hypertensive emergency as a cause for ACS.