Outpatient diagnosis of acute chest pain in adults

The Ohio State University, Columbus, OH, USA.
American family physician (Impact Factor: 2.18). 02/2013; 87(3):177-82.
Source: PubMed


Approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction. The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities). Persons with a higher likelihood of acute coronary syndrome should be referred to the emergency department or hospital.

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    • "Approximately 1% of primary care visits are related to chest pain, and 1.5% of these individuals will have unstable angina or acute MI. A quick and cost-effective means of ruling out cardiac causes is a 12-lead EKG to evaluate for such instances as the following: ST segment depressions or elevations; new onset of left bundle branch block; suggestions of old infarct such as Q waves; or new onset of T wave inversions.1 Chest pain or symptoms thought to be related to myocardial ischemia or infarction account for 8%–10% of the 119 million emergency department visits that occur yearly in the United States.2 "
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    ABSTRACT: Cardiac Syndrome X (CSX), characterized by angina-like chest discomfort, ST segment depression during exercise, and normal epicardial coronary arteries at angiography, is highly prevalent in women. CSX is not benign, and linked to adverse cardiovascular outcomes and a poor quality of life. Coronary microvascular and endothelial dysfunction and abnormal cardiac nociception have been implicated in the pathogenesis of CSX. Treatment includes life-style modification, anti-anginal, anti-atherosclerotic, and anti-ischemic medications. Non-pharmacological options include cognitive behavioral therapy, enhanced external counterpulsation, neurostimulation, and stellate ganglionectomy. Studies have shown the efficacy of individual treatments but guidelines outlining the best course of therapy are lacking.
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