Department of Family Medicine, University of North Carolina at Chapel Hill (Drs. Lam and Mounsey); Naval Hospital Camp Lejeune, NC, and Uniformed Services University of the Health Sciences, Bethesda, MD (Dr. Hwang) Anne_Mounsey@med.unc.edu
The authors reported no potential conflict of interest relevant to this article.
The contents of this article are solely the views of the authors and do not necessarily represent the official views of the Uniformed Services University of the Health Sciences, the US Navy, the US military at large, the US Department of Defense, or the US government.
Which history and exam findings have high predictive value for different causes of chest pain? Which decision tool can best assess for CAD in your practice setting?
› Use the highly sensitive Marburg Heart Score to rule out coronary artery disease as a cause of chest pain in the ambulatory care setting. B
› Consider a prior normal stress test result nonpredictive of outcome in a patient presenting with chest pain. Patients with such a history of testing have a risk of a 30-day adverse cardiac event that is similar to the risk seen in patients who have never had a stress test. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence, case series
a Risk factors include hypertension, hypercholesterolemia, diabetes, obesity (body mass index > 30), smoking (current, or smoking cessation for ≤ 3 mo), and family history of CAD (ie, parent or sibling affected before 65 years of age). Atherosclerotic disease includes history of AMI, percutaneous coronary intervention or coronary artery bypass grafting, stroke, or peripheral artery disease.
References
One of the most concerning and challenging patient complaints presented to physicians is chest pain. Chest pain is a ubiquitous complaint in primary care settings and in the emergency department (ED), accounting for 8 million ED visits and 0.4% of all primary care visits in North America annually.1,2
Acute coronary syndrome is the cause of chest pain in 5.1% of patients with chest pain who present to the ED, compared with 1.5% to 3.1% of chestpain patients seen in ambulatory care.
Despite the great number of chest-pain encounters, early identification of life-threatening causes and prompt treatment remain a challenge. In this article, we examine how the approach to a complaint of chest pain in a primary care practice (and, likewise, in the ED) must first, rest on the clinical evaluation and second, employ risk-stratification tools to aid in evaluation, appropriate diagnosis, triage, and treatment.
Chest pain by the numbers
Acute coronary syndrome (ACS) is the cause of chest pain in 5.1% of patients with chest pain who present to the ED, compared with 1.5% to 3.1% of chest-pain patients seen in ambulatory care.1,3 “Nonspecific chest pain” is the most frequent diagnosis of chest pain in the ED for all age groups (47.5% to 55.8%).3 In contrast, the most common cause of chest pain in primary care is musculoskeletal (36%), followed by gastrointestinal disease (18% to 19%); serious cardiac causes (15%), including ACS (1.5%); nonspecific causes (16%); psychiatric causes (8%); and pulmonary causes (5% to 10%).4 Among patients seen in the ED because of chest pain, 57.4% are discharged, 30.6% are admitted for further evaluation, and 0.4% die in the ED or after admission.3
The differential diagnosis of chest pain is broad. It includes life-threatening causes, such as ACS (from ST-segment elevation myocardial infarction [STEMI], Type 1 non-STEMI, and unstable angina), acute aortic dissection, pulmonary embolism (PE), esophageal rupture, and tension pneumothorax, as well as non-life-threatening causes (TABLE 1).
History and physical exam guide early decisions
Triage assessment of the patient with chest pain, including vital signs, general appearance, and basic symptom questions, can guide you as to whether they require transfer to a higher level of care. Although an individual’s findings cannot, alone, accurately exclude or diagnose ACS, the findings can be used in combination in clinical decision tools to distinguish noncardiac chest pain from ACS.
History.Features in the history (TABLE 25-9) that are most helpful at increasing the probability (ie, a positive likelihood ratio [LR] ≥ 2) of chest pain being caused by ACS are:
pain radiating to both arms or the right arm
pain that is worse upon exertion
a history of peripheral artery disease or coronary artery disease (CAD)
a previously abnormal stress test.
The presence of any prior normal stress test is unhelpful: Such patients have a similar risk of a 30-day adverse cardiac event as a patient who has never had a stress test.5
IMAGE: © KIMBERLY MARTENS-KIEFER
