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Diagnosing the Cause of Chest Pain WILLIAM E Diagnosing the Cause of Chest Pain WILLIAM E. CAYLEY, JR., M.D., Eau Claire Family Medicine Residency, Eau Claire, Wisconsin Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneu- monia. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measure- ment of troponin levels and cardiac stress testing. 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. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. Although some patients with chest pain have heart failure, this is unlikely in the absence of dys- pnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Pain reproducible by palpation is more likely to be mus- culoskeletal than ischemic. Chest pain also may be associated with panic disorder, for which patients can be screened with a two-item questionnaire. Clinical prediction rules can help clarify many of these diagnoses. (Am Fam Physician 2005;72:2012-21. Copyright © 2005 American Academy of Family Physicians.) KARAPELOU W. JOHN BY ILLUSTRATION hest pain is the chief complaint definitive diagnosis.3,4 Despite these figures, in about 1 to 2 percent of out- when evaluating chest pain in primary care patient visits,1 and although the it is important to consider serious conditions cause is often noncardiac, heart such as stable or unstable CAD, PE, and pneu- Cdisease remains the leading cause of death monia, in addition to more common (but less in the United States.2 Thus, distinguishing serious) conditions such as chest wall pain, between serious and benign causes of chest peptic ulcer disease, gastroesophageal reflux pain is imperative, and diagnostic and prog- disease (GERD), and panic disorder. nostic questions are important in making this determination. Clinical Diagnosis The epidemiology of chest pain differs Chest pressure with dyspnea commonly leads markedly between outpatient and emergency physicians and other health care profession- settings. Cardiovascular conditions such as als to consider an acute coronary syndrome myocardial infarction (MI), angina, pulmo- such as unstable angina or MI, but these nary embolism (PE), and heart failure are symptoms also may represent chest wall pain found in more than 50 percent of patients or PE. Dyspnea is common in patients with presenting to the emergency department with heart failure, whereas dyspnea with fever is chest pain,3 but the most common causes of characteristic of pneumonia and bronchitis. chest pain seen in outpatient primary care The usual descriptions of peptic ulcer disease are musculoskeletal conditions, gastrointes- and GERD include epigastric discomfort and tinal disease, stable coronary artery disease retrosternal burning, but often it is difficult (CAD), panic disorder or other psychiatric to distinguish clearly between classic “heart- conditions, and pulmonary disease (Table burn” and classic “chest pressure.” Although 1).3,4 Unstable CAD rarely is the cause of it often is thought that symptoms of anxiety chest pain in primary care, and around 15 can help distinguish pulmonary diseases percent of chest pain episodes never reach a from other causes of chest pain, this is not a 2012 American Family Physician www.aafp.org/afp Volume 72, Number 10 U November 15, 2005 SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Determining whether chest pain is anginal, atypical anginal, or non- C16 anginal is recommended to help determine a patient’s cardiac risk. The Rouan decision rule is recommended to help predict which patients C17 are at higher risk of MI. A Wells score of less than 2 plus a normal D-Dimer assay should rule A20, 32, 33 out PE. In patients with an abnormal D-Dimer assay or a Wells score indicating A33, 35 moderate to high risk, helical CT and lower extremity venous ultrasound examination should be used to rule in or rule out PE. The Diehr diagnostic rule is recommended to predict the likelihood A11 of pneumonia based on clinical findings. Patients should be screened for panic disorder using two set questions. C 14 Patients presenting with chest pain should have an ECG evaluation for C 7, 9 ST segment elevation, Q waves, and conduction defects. Results should be compared with previous tracings. Serum troponin–level testing is recommended to aid in the diagnosis C25, 28, 29 of MI and help predict the likelihood of death or recurrent MI within 30 days. Patients with chest pain and a negative initial cardiac evaluation should C16 have further testing with stress ECG, perfusion scanning, or angiography depending on their level of risk. The Duke treadmill score is recommended to help predict long-term A 31 prognosis for patients undergoing stress ECG testing. MI = myocardial infarction; PE = pulmonary embolism; CT = computed tomography; ECG = electrocardiography. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1949 or http://www.aafp.org/afpsort.xml. TABLE 1 Epidemiology of Chest Pain in Primary Care and Emergency Department Settings Percentage of patients presenting with chest pain Primary care: Primary care: Emergency Diagnosis* United States4 Europe3 department3 Musculoskeletal condition 36 29 7 Gastrointestinal disease 19 10 3 Serious cardiovascular disease† 16 13 54 Stable coronary artery disease 10 8 13 Unstable coronary artery disease 1.5 — 13 Psychosocial or psychiatric disease 8 17 9 Pulmonary disease‡ 52012 Nonspecific chest pain 16 11 15 *—Diagnoses are listed in order of prevalence in United States. †—Including infarction, unstable angina, pulmonary embolism, and heart failure. ‡ —Including pneumonia, pneumothorax, and lung cancer. Adapted with permission from Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. J Fam Pract 1994;38:349, with additional information from reference 3. November 15, 2005 U Volume 72, Number 10 www.aafp.org/afp American Family Physician 2013 Chest Pain Dx TABLE 2 Accuracy of Chest Pain Diagnosis Using the History and Physical Examination Probability of diagnosis (%) if finding is: Diagnosis* (overall outpatient probability) Clinical finding LR+ LR- Present Absent Myocardial Chest pain radiates to 7.10 0.67 13 1 infarction (2%)4 both arms5 Hypotension6 3.80 0.96 7 2 7 S3 gallop 3.20 0.88 6 2 Diaphoresis8,9 2.00 0.64 4 1 Pleuritic chest pain7 0.17 1.20 <1 2 Palpation of tender area 0.16 1.20 <1 2 reproduces chest pain8 Pneumonia (5%)10,11 Egophony11 8.60 0.96 31 5 Dullness to percussion10 4.30 0.79 18 4 Fever11 2.10 0.71 10 4 Heart failure (2%)12 Exertional dyspnea13 1.20 0 2 < 1 Displaced apical impulse13 17.00 0.35 26 1 Panic disorder (8%)4 “Yes” on at least one item 1.30 0.60 10 1 of Autonomic Nervous System Questionnaire14† Chest wall pain (36%)4 Palpation of tender area 12.00 0.78 87 30 reproduces chest pain15 LR+ = positive likelihood ratio; LR = negative likelihood ratio. *—Diagnoses are listed in order of clinical importance. †—Screening questions: (1) “In the past six months, did you ever have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy?” and (2) “In the past six months, did you ever have a spell or an attack when for no reason your heart suddenly began to race, you felt faint, or you could not catch your breath?”14 Information from references 4 through 15. consistent finding and should not be relied decision rules that combine key groups of upon. There is enough overlap among the symptoms. clinical manifestations of different causes of chest pain to make “classic” symptoms HISTORY AND PHYSICAL EXAMINATION unhelpful in differentiating among diag- It is important to obtain a clear history of noses and ruling out serious causes. How- the onset and evolution of chest pain, with ever, there are several validated clinical particular attention to details such as loca- tion, quality, duration, and aggravating or alleviating factors. Certain key symptoms The Author and clinical findings can help rule in or out 4-15 WILLIAM E. CAYLEY, JR., M.D., M.DIV., is assistant professor at the Eau Claire specific diagnoses (Table 2). (Wis.) Family Medicine Residency, University of Wisconsin, Eau Claire. He received Determining whether pain is (1) sub- his medical degree from the Medical College of Wisconsin, Milwaukee, and com- sternal, (2) provoked by exertion, or (3) pleted a residency at the Eau Claire Family Medicine Residency, Eau Claire. relieved by rest or nitroglycerin helps to clar- Address correspondence to William E. Cayley, Jr., M.D., M.Div., Eau Claire Family ify whether it is typical anginal pain (has all Medicine Residency, 617 W. Clairemont, Eau Claire, WI 54701 (e-mail: bcayley@ three characteristics), atypical anginal pain yahoo.com). Reprints are not available from the author. (has two characteristics), or nonanginal 2014 American Family Physician www.aafp.org/afp Volume 72, Number 10 U November 15, 2005 Chest Pain Dx at higher risk for MI (Table 3).17 However, TABLE 3 because up to 3 percent of patients initially Rouan Decision Rule diagnosed with a noncardiac cause of chest for Myocardial Infarction pain suffer death or MI within 30 days of presentation, patients with cardiac risk fac- Clinical Characteristics tors such as male sex, greater age, diabetes, Age greater than 60 years hyperlipidemia, prior CAD, or heart failure 19 Diaphoresis warrant close follow-up.
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