Pain may also occur in these areas indepen- dent of chest pain. Patients with NSTE-ACS may also present with diaphoresis, dyspnea, nausea, abdominal pain, or syn- cope. Unexplained new-onset or increased exertional dyspnea is the most common angina equivalent. Less common presen- tations include nausea and vomiting, diaphoresis, unexplained fatigue, and syncope. Factors that increase the probability of NSTE-ACS are older age, male sex, positive family history of CAD, and the presence of peripheral arterial disease, diabe- tes mellitus, renal insufficiency, prior MI, and prior coronary revascularization. Although older patients ( 75 years of age) and women usually present with typical symptoms of ACS, the frequency of atypical presentations is increased in these groups as well as in patients with diabetes mellitus, impaired renal function, and dementia.54,55 Atypical symptoms, includ- ing epigastric pain, indigestion, stabbing or pleuritic pain, and increasing dyspnea in the absence of chest pain should raise concern for NSTE-ACS.56 Psychiatric disorders (eg, somato- form disorders, panic attack, anxiety disorders) are noncardiac causes of chest pain that can mimic ACS.57 3.2.2. Physical Examination The physical examination in NSTE-ACS can be normal, but signs of HF should expedite the diagnosis and treatment of Amsterdam et al 2014 AHA/ACC NSTE-ACS Guideline e353 this condition. Acute myocardial ischemia may cause a S4 , a paradoxical splitting of S2 , or a new murmur of mitral regur- gitation due to papillary muscle dysfunction. However, these signs may also exist without NSTE-ACS and thus are nonspe- cific. The coupling of pain on palpation suggesting musculo- skeletal disease or inflammation with a pulsatile abdominal mass suggesting abdominal aortic aneurysm raises concern for nonischemic causes of NSTE-ACS. The physical exami- nation can indicate alternative diagnoses in patients with chest pain, several of which are life threatening. 