Evaluation of Chest Pain

William Norcross, M.D.

 Evaluation of Chest Pain

• Dictum:
• With any chief complaint or symptom complex, first rule-
out (R/O) life threats.
• The stopping point in the R/O should be at the point of
your conviction and personal satisfaction that the life
threat does not exist.
• The R.O process may be very short and simple, e.g. a
directed histroy, but if you're not convinced that the life
threat is absent, pursue the R/O as far as necessary.
 Chest Pain is very common.

• > 40 recognized entities in differential diagnosis

• Life threat (practical)
• Acute coronary syndromes (ACS)
• Aortic dissection
• Pulmonary embolus (PE)
• Pneumothorax
• Pneumonia
• Obscure
• Boerhave’s Syndrome
• Usually are discovered in W/U of above.
 Life-Threat Ruled Out
• Other entities
• Musculoskeletal/serosal problems
• e.g. costochondritis, intercostal muscle spasms/strain,
pericarditis, pleurisy
• Treat with NSAID, opiates, acetaminophen, local measures
• GI pathology
• Dyspepsia, GE reflux esophageal spasm
• Some bad abdominal pathology presents as chest pain
– e.g. perfodrated viscous, pancreatitis, cholecystitis
– Usually apparent by H&P
• Treat with antacids, antispsmodics, etc.
 Approach to Non-Life Threats

• Less urgent
• Trial & error approach
• Evaluation
• H&P, ancillary tests (CRX, EKG, perhaps dimers and
cardiac markers)
 Approach to Non-Life Threats

• Pneumonia, pneumothorax easy to diagnose

• Note: the diagnostic modality for tension pneumothorax is an
intracostal needle, not a CXR.
• ACS, PE, aortic dissection: all easy to diagnose if
you do the work-up
• Triggered by suspicions raised by initial evaluation
and R/O life threat
 Bad things to miss

• High mortality out-of-hospital (if undiagnosed)

 Pulmonary Embolism
• Physical exam: tachycardia, tachypnea, sats, R
heart findings, leg findings
• Ancillary - EKG, CXR, nonspecific d-dimer is usually
 (sensitivity > 85%)
• Assign likelihood of PE (low, high, intermediate)
based on clinical gestalt or grading scales (e.g.
Well’s Criteria)
• If low probability and d-dimer is , quit (probably)
• If intermediate or high, or if low with  d-dimer, further
study (V/Q, CT angio, perhaps dopplers)
 Aortic dissection
• History triggers; sudden,radiation, ripping/tearing
• Risk factors: HTN, Marfan’s, coarctation, aortic valve
replacement, bicuspid aorta
• PE:
• Severe pain, distress (usually), pulses, BP differential, AI
murmur, neuro deficits
• All are insensitive markers, varied specificity
• Ancillary data
• CXR: usually abn (90%) wide mediastinum, abn aorta;
non-specific, 10% “normal”
• EKG: may show ST segment elevation
 Acute Coronary Syndrome

• Most important due to commonality as well as

lethality
• Top of differential, first inquiry
• ‘ACS’ against the field of everything else
 ACS

• History: Full history

Only 4 things are truly predictive of ACS
1. Presence of chest pain
2. Chest pain as chief complaint
3. Radiation to shoulder(s)
4. History of previous MI
• Risk factors (traditional) are not predictive in ED
setting
 ACS
• PE: full physical
• Only 4 things predictive:
1. Hypotension
2. Diaphoresis
3. Rales
4. S3
• Markers
• CKMB | troponin : sensitivity < 50% at 6 hrs
• Neg markers with unstable angina and often initially
neg with MI
• Neg first set mandates at lest on additional set
 ACS: EKG
• Diagnostic of MI (1 mm elevation ST segments in
anatomically contiguous leads) about 50% of the time.
• Non-diagnostic (usually non-specific ST/T waves) in around
50% MI.
• Normal 5 - 10% MI
• If ST  as above there is 80% likelihood of AMI
• If new ST 1 mm with inverted T in anatomically
contiguouse leads, 20% chance of AMI, 20 -- 50% change
unstable angina (UA).
• If old ST changes as above and acute chest pain, 5%
chance AMI and 20 - 50% UA.
 Acute Coronary Syndrome

• If ACS is Ruled In (with EKG or markers) treat and

admit.
• If not, then:
• If strong suspicion, teat, admit, further R/O
• If convinced not ACS (or other potentially serious
problem) -
• treat symptoms, outpatient manage
• If unsure -
• treat, admit, further R/O
 ACS

• Approached with clinical gestalt.

• More objective decision aids available (ACI - TIPI).
• Clinical sensitivity of either approach, > 95%.
• Not good enough: the 5% (approximate) do badly.

• If in doubt, assume the worst, treat and admit for

further evaluation.
 References
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