Cardiovascular conditions such as myocardial infarction (MI), angina, pulmonary embolism (PE), and heart failure are found in more than 50 percent of patients presenting to the emergency department with chest pain, 3 but the most common causes of chest pain seen in outpatient primary care are musculoskeletal conditions, gastrointestinal disease, stable coronary artery disease (CAD), panic disorder or other psychiatric conditions, and pulmonary disease ( Table 1). The epidemiology of chest pain differs markedly between outpatient and emergency settings. The Duke treadmill score is recommended to help predict long-term prognosis for patients undergoing stress ECG testing. Patients with chest pain and a negative initial cardiac evaluation should have further testing with stress ECG, perfusion scanning, or angiography depending on their level of risk. Serum troponin–level testing is recommended to aid in the diagnosis of MI and help predict the likelihood of death or recurrent MI within 30 days. Results should be compared with previous tracings. Patients presenting with chest pain should have an ECG evaluation for ST segment elevation, Q waves, and conduction defects. Patients should be screened for panic disorder using two set questions. The Diehr diagnostic rule is recommended to predict the likelihood of pneumonia based on clinical findings. In patients with an abnormal d-dimer assay or a Wells score indicating moderate to high risk, helical CT and lower extremity venous ultrasound examination should be used to rule in or rule out PE.
Does all my patients all have chest pain plus#
The Rouan decision rule is recommended to help predict which patients are at higher risk of MI.Ī Wells score of less than 2 plus a normal d-dimer assay should rule out PE. Clinical prediction rules can help clarify many of these diagnoses.ĭetermining whether chest pain is anginal, atypical anginal, or nonanginal is recommended to help determine a patient’s cardiac risk. Chest pain also may be associated with panic disorder, for which patients can be screened with a two-item questionnaire.
Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea a brain natriuretic peptide level measurement can clarify the diagnosis. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. Risk of pulmonary embolism can be determined with a simple prediction rule, and a d-dimer assay can help determine whether further evaluation with helical computed tomography or venous ultrasound is needed. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. Chest pain presents a diagnostic challenge in outpatient family medicine.
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