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  • Pain onset, character, location/size, duration, periodicity, and exacerbators; shortness of breath.

  • Vital signs; chest and cardiac examinations.

  • ECG and biomarkers of myocardial necrosis in selected patients.


Chest pain (or chest discomfort) can occur as a result of cardiovascular, pulmonary, pleural, or musculoskeletal disease; esophageal or other GI disorders (including a foreign body, eg, a fish bone); herpes zoster; cocaine use; or anxiety states. The frequency and distribution of life-threatening causes of chest pain, such as acute coronary syndrome (ACS), pericarditis, aortic dissection, vasospastic angina, PE, pneumonia, and esophageal perforation, vary substantially between clinical settings. There are more than 8 million emergency department visits in the United States every year for acute undefined chest pain. However, inpatient admission rate for chest pain declined from 19% in 2006 to 3.9% in 2016.

In the Netherlands and Belgium, chest pain was the reason for consulting the general practitioner in 1.26% of all cases. In 8.4% of patients with chest pain, life-threatening underlying causes were identified. SLE, rheumatoid arthritis, reduced eGFR, and HIV infection are conditions that confer a strong risk of CAD. Precocious ACS (occurring in patients aged 35 years or younger) may represent acute thrombosis independent of underlying atherosclerotic disease. Risk factors for precocious ACS are obesity, hyperlipidemia, and smoking.

Although ACS presents with a broader range of symptoms in women than men, specific chest pain characteristics of acute MI do not differ in frequency or strength between men and women.

Women are four times more likely than men to have coronary microvascular dysfunction (adjusted OR, 4.2) after controlling for age, race, hypertension, diabetes, smoking, dyslipidemia, obesity, and family history of CAD.

Because PE can present with a wide variety of symptoms, consideration of the diagnosis and rigorous risk factor assessment for venous thromboembolism (VTE) is critical. Classic VTE risk factors include cancer, trauma, recent surgery, prolonged immobilization, pregnancy, oral contraceptives, and family history and prior history of VTE. Other conditions associated with increased risk of PE include HF and COPD. Sickle cell anemia can cause acute chest syndrome. Patients with this syndrome often have chest pain, fever, and cough. Carbon monoxide poisoning may trigger coronary artery spasm. Increased circulatory volume during transfusion may cause chest pain secondary to myocardial demand ischemia in at-risk patients.


A. Symptoms

Myocardial ischemia is usually described as a dull, aching sensation of “pressure,” “tightness,” “squeezing,” or “gas,” rather than as sharp or spasmodic. Pain reaching maximum intensity in seconds is uncommon. Ischemic symptoms usually subside within 5–20 minutes but may last longer. Progressive symptoms or symptoms at rest may represent unstable angina. Up to one-third of patients with acute MI do not report chest pain. Chest pain is present in more than 90% of patients having a STEMI who are under age 65 but ...

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