Diagnosing Acute Coronary Syndrome: A Challenge for General Practitioners and Cardiologists

Abstract

Three patients present with chest pain to their general practitioner. In all three cases, the patient is suspected of acute coronary syndrome (ACS). In the first case, a coronary artery disease causing the complaints is ruled out since troponin levels remain within the normal range. In the second case, troponin is elevated due to non STelevated myocardial infarction. In the third case, troponin is elevated due to cardiac cell damage in severe pneumonia (i.e. cardiac damage is not caused by a coronary artery occlusion). In cardiology, diagnostic tools for ruling ACS in or out are becoming increasingly sensitive. In general practice, diagnostic means to discriminate between ACS and less severe causes of chest complaints remain poor. Both situations challenge physicians working in their respective fields. Cardiologists must deal with a decrease in testing specificity due to the increasing analytical sensitivity of high-sensitivity troponin, and face the dilemma of whether or not to perform invasive coronary angiography in cases of doubt instead of while general practitioners are still lacking adequate diagnostic tools. These difficulties are illustrated in three cases where patients’ present chest complaints in primary care and are eventually referred to a cardiologist. Notwithstanding the presence of the aforementioned dilemmas, combining clinical reasoning with current definitions of ACS and myocardial infarction leads to an unambiguous diagnosis in all three cases.