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: Suspected acute coronary syndrome (ACS) represents a substantial healthcare problem and is responsible for a large proportion of emergency department admissions. Better triaging of patients with suspected ACS is needed to facilitate early initiation of appropriate therapy in patients with acute myocardial infarction (AMI) and to exclude low-risk patients who can safely be sent home, thereby limiting healthcare costs. H-FABP has been established as the earliest available plasma marker for myocardial injury. In this review we evaluate the clinical utility of H-FABP for suspected ACS. H-FABP shows added value in addition to cardiac troponin, especially in the early hours after onset of symptoms. Moreover, H-FABP identifies patients at increased risk for future cardiac events. It is concluded that measuring H-FABP along with troponin shortly after onset of symptoms improves risk stratification of patients suspected of having ACS in a cost-effective manner.
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