What signs and symptoms point to a serious cause of chest pain?
What key historical elements will help to narrow the differential diagnosis?
What studies should be ordered?
According to the 2006 National Hospital Ambulatory Medical Care Survey, 6,392,000 patients presented to emergency departments with a chief complaint of chest pain or related symptoms. Of those, 1,976,000 patients were admitted to the hospital, with a mean length of stay of 3.7 days. Chest pain was the principal admitting diagnosis in 5.4% of all admitted patients.
Because the morbidity and mortality is high if clinicians “miss” a cardiac presentation of chest pain, a significant portion of these admissions are specifically for the purpose of ruling out myocardial infarction. In one study of patients presenting to an emergency department with complaints consistent with cardiac ischemia, 17% ultimately had cardiac ischemia, while 27% had stable angina or other cardiac conditions. Fifty-five percent had noncardiac conditions causing their symptoms. The wide differential diagnosis for this heterogeneous group of patients includes nonischemic life-threatening etiologies as well as more benign causes. Unfortunately, in this study, 2.1% of the patients with acute myocardial infarction were erroneously discharged; this figure plays prominently in the low threshold to admit patients with chest pain.
Chest pain also occurs in patients already admitted to the hospital for other reasons. These patients have already suffered some degree of physical decompensation and the occurrence of chest pain may indicate illness, a complication of hospitalization, or a patient's response to a very stressful situation. The hospitalist must evaluate the possibility of an immediate life-threatening event, consider the entire differential of possible etiologies, and integrate this information with the patient's prior clinical diagnoses and course.
The initial evaluation of a patient reporting chest pain requires the rapid identification and treatment of any life-threatening conditions. These include the five “do-not-miss” causes of chest pain: (1) aortic dissection, (2) acute myocardial infarction, (3) pulmonary embolism, (4) pneumothorax, and (5) esophageal rupture (Table 77-1) . The electrocardiogram (ECG) is the most important screening intervention for early risk stratification and is often performed at the point of triage as one of the “vital signs.”
Table 77-1 Life-Threatening Causes of Chest Pain |Favorite Table|Download (.pdf)
Table 77-1 Life-Threatening Causes of Chest Pain
|Diagnosis||Risk Factors||Characteristic Findings||Diagnostic Testing|
|Aortic dissection||Hypertension, connective tissue disease, vasculitis, prior heart or valvular surgery, Turner syndrome, crack cocaine use, cardiac catheterization||New diastolic murmur, upper-extremity pulse deficit, neurologic complications of stroke||Computed tomography, magnetic resonance imaging, transesophageal echocardiography, angiography|
|Special considerations: Aortic dissection can be difficult to diagnose, but patients will most commonly present with chest pain; syncope may occur at the time of symptom onset. Dissections can be classified as Stanford type A (involving the ascending aorta) or type B (all others). In one study, 72.7% of patients ...|