Acute Chest Pain in Adults: Outpatient Evaluation


Approximately 1% of primary care office visits are for chest pain, and 2% to 4% of these patients will have unstable angina or myocardial infarction. Initial evaluation is based on determining whether the patient needs to be referred to a higher level of care to rule out acute coronary syndrome (ACS). A combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease as the cause of chest pain. The Marburg Heart Score and the INTERCHEST clinical decision rule can also help estimate ACS risk. Twelve-lead electrocardiography is recommended to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions. Patients with suspicion of ACS or changes on electrocardiography should be transported immediately to the emergency department. Those at low or intermediate risk of ACS can undergo exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging. In those with low suspicion for ACS, consider other diagnoses such as chest wall pain or costochondritis, gastroesophageal reflux disease, and panic disorder or anxiety states. Other less common, but important, diagnostic considerations include acute pericarditis, pneumonia, heart failure, pulmonary embolism, and acute thoracic aortic dissection.

Approximately 1% of all ambulatory visits in primary care settings are for chest pain.1 Cardiac disease is the leading cause of death in the United States, yet only 2% to 4% of patients presenting to a primary care office with chest pain will have unstable angina or an acute myocardial infarction.24 The most common causes of chest pain in the primary care population are chest wall pain (20% to 50%), reflux esophagitis (10% to 20%), and costochondritis (13%).2 Other potential factors include pulmonary etiologies (pneumonia, pulmonary embolism [PE]), psychological etiologies (panic disorder), and nonischemic cardiovascular disorders (congestive heart failure, thoracic aortic dissection).2,3,5,6 No definitive diagnosis may be found in as many as 15% of patients.2 Differentiating ischemic from nonischemic causes is often challenging because patients with ischemic chest pain may appear well. As such, the initial diagnostic approach should always consider a cardiac etiology for the chest pain unless other causes are apparent.7

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Clinical recommendationEvidence ratingComments

When patients present to the primary care office with chest pain, physicians should consider age, sex, and type of chest pain to predict the likelihood that it is acute coronary syndrome caused by coronary artery disease.15


Large prospective cohort study

Physicians should consider using a validated clinical decision rule such as the INTERCHEST rule or the Marburg Heart Score to stratify risk in patients with chest pain.1720


Smaller clinical trials of validated decision rules

Twelve-lead electrocardiography should be performed on all patients in whom cardiac ischemia is suspected. The presence of ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversion increases the likelihood of acute coronary syndrome and acute myocardial infarction; these patients should be referred immediately to the emergency department.21,22


Clinical reviews and consensus expert opinion

Patients who have chest pain with a low to intermediate probability of coronary artery disease not requiring immediate referral to the emergency department should be evaluated for coronary artery disease with exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging.2327


Unblinded randomized controlled trials and clinical reviews

Patients with localized musculoskeletal pain that is reproducible by palpation or pain reproducible by palpation of the parasternal costochondral joints likely have chest wall pain or costochondritis.29,30


Clinical reviews and consensus expert opinion

Gastroesophageal reflux disease should be considered in patients with burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth.31,32


Clinical review and observational studies

Panic disorder and anxiety states often cause chest pain and shortness of breath; physicians should consider using a single validated screening question to confirm the diagnosis.35


Validation of a clinical prediction rule

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to


Clinical recommendationEvidence ratingComments

When patients present to the primary care office with chest pain, physicians should

The Authors

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JOHN R. MCCONAGHY, MD, is a professor of family and community medicine, department vice chair, and the associate director of the Family Medicine Residency Program at The Ohio State University Wexner Medical Center, Columbus....

MALVIKA SHARMA, MD, is a resident in the Family Medicine Residency Program at The Ohio State University Wexner Medical Center.

HITEN PATEL, MD, is an ultrasound fellow in the Family Medicine Residency Program at The Ohio State University Wexner Medical Center. At the time the article was written, Dr. Patel was chief resident.

Address correspondence to John R. McConaghy, MD, The Ohio State University Wexner Medical Center, 2231 N High St., Columbus, OH 43201 (email: Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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1. Rui P, Okeyode T. National ambulatory medical care survey: 2016 national summary tables. Accessed December 28, 2019.

2. Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract. 1994;38(4):345–352.

3. Will JC, Loustalot F, Hong Y. National trends in visits to physician offices and outpatient clinics for angina 1995 to 2010. Circ Cardiovasc Qual Outcomes. 2014;7(1):110–117.

4. Heron M. Deaths: leading causes for 2017. National Vital Statistics Reports. National Center for Health Statistics. June 24, 2019. Accessed January 8, 2020.

5. Svavarsdóttir AE, Jónasson MR, Gudmundsson GH, et al. Chest pain in family practice. Diagnosis and long-term outcome in a community setting [published correction appears in Can Fam Physician. 1996;42:1672]. Can Fam Physician. 1996;42:1122–1128.

6. Ebell MH. Evaluation of chest pain in primary care patients. Am Fam Physician. 2011;83(5):603–605. Accessed September 15, 2020.

7. Kontos MC, Diercks DB, Kirk JD. Emergency department and office-based evaluation of patients with chest pain. Mayo Clin Proc. 2010; 85(3):284–299.

8. Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA focused update of the guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [published corrections appear in Circulation. 2011;124(12):e337–e340 and Circulation. 2011;123(22):e625–e626]. Circulation. 2011;123(18):2022–2060.

9. Braunwald E. Unstable angina. A classification. Circulation. 1989;80(2):410–414.

10. Thygesen K, Alpert JS, Jaffe AS, et al.; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol. 2018;72(18):2231–2264.

11. National Clinical Guideline Centre for Acute and Chronic Conditions (UK). Chest Pain of Recent Onset: Assessment and Diagnosis. NICE clinical guideline no. 95. Royal College of Physicians; 2010.

12. Rouan GW, Lee TH, Cook EF, et al. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol. 1989;64(18):1087–1092.

13. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes [published correction appears in JAMA. 2006;295(19):2250]. JAMA. 2005;294(20):2623–2629.

14. Bösner S, Becker A, Abu Hani M, et al. Accuracy of symptoms and signs for coronary heart disease assessed in primary care. Br J Gen Pract. 2010;60(575):e246–e257.

15. Bittencourt MS, Hulten E, Polonsky TS, et al. European Society of Cardiology—recommended coronary artery disease consortium pretest probability scores more accurately predict obstructive coronary disease and cardiovascular events than the Diamond and Forrester score: the Partners Registry [published correction appears in Circulation. 2018; 138(5):e80]. Circulation. 2016;134(3):201–211.

16. Amsterdam EA, Wenger NK, Brindis RG, et al.; ACC/AHA Task Force members. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2014;130(25):e433–e434]. Circulation. 2014;130(25):e344–e426.

17. Harskamp RE, Laeven SC, Himmelreich JCI, et al. Chest pain in general practice: a systematic review of prediction rules. BMJ Open. 2019;9(2):e027081.

18. Haasenritter J, Bösner S, Vaucher P, et al. Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule. Br J Gen Pract. 2012;62(599):e415–e421.

19. Aerts M, Minalu G, Bösner S, et al.; International Working Group on Chest Pain in Primary Care (INTERCHEST). Pooled individual patient data from five countries were used to derive a clinical prediction rule for coronary artery disease in primary care. J Clin Epidemiol. 2017;81:120–128.

20. Sox HC, Aerts M, Haasenritter J. Applying a clinical decision rule for CAD in primary care to select a diagnostic test and interpret the results [Point-of-Care Guide]. Am Fam Physician. 2019;99(9):584–586. Accessed September 15, 2020.

21. Thygesen K, Alpert JS, Jaffe AS, et al.; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. Circulation. 2012;126(16):2020–2035.

22. Rude RE, Poole WK, Muller JE, et al. Electrocardiographic and clinical criteria for recognition of acute myocardial infarction based on analysis of 3,697 patients. Am J Cardiol. 1983;52(8):936–942.

23. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) [published correction appears in J Am Coll Cardiol. 2006;48(8):1731]. J Am Coll Cardiol. 2002;40(8):1531–1540.

24. Metz LD, Beattie M, Hom R, et al. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis. J Am Coll Cardiol. 2007;49(2):227–237.

25. Newby DE, Adamson PD, Berry C, et al.; SCOT-HEART Investigators. Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med. 2018;379(10):924–933.

26. Yin X, Wang J, Zheng W, et al. Diagnostic performance of coronary computed tomography angiography versus exercise electrocardiography for coronary artery disease: a systematic review and meta-analysis. J Thorac Dis. 2016;8(7):1688–1696.

27. Nagel E, Greenwood JP, McCann GP, et al.; MR-INFORM Investigators. Magnetic resonance perfusion or fractional flow reserve in coronary disease. N Engl J Med. 2019;380(25):2418–2428.

28. Healthcare bluebook. Accessed May 7, 2020.

29. Bösner S, Becker A, Abu Hani M, et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Fam Pract. 2010;27(4):363–369.

30. Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466–2469.

31. Zimmerman J. Validation of a brief inventory for diagnosis and monitoring of symptomatic gastro-oesophageal reflux. Scand J Gastroenterol. 2004;39(3):212–216.

32. Mousavi S, Tosi J, Eskandarian R, et al. Role of clinical presentation in diagnosing reflux-related non-cardiac chest pain. J Gastroenterol Hepatol. 2007;22(2):218–221.

33. Wang WH, Huang JQ, Zheng GF, et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis. Arch Intern Med. 2005;165(11):1222–1228.

34. Huffman JC, Pollack MH, Stern TA. Panic disorder and chest pain: mechanisms, morbidity, and management. Prim Care Companion J Clin Psychiatry. 2002;4(2):54–62.

35. Löwe B, Gräfe K, Zipfel S, et al. Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians' diagnosis. J Psychosom Res. 2003;55(6): 515–519.

36. Imazio M, Gaita F, LeWinter M. Evaluation and treatment of pericarditis: a systematic review [published corrections appear in JAMA. 2016;315(1):90 and JAMA. 2015;314(18):1978]. JAMA. 2015;314(14):1498–1506.

37. Kaysin A, Viera AJ. Community-acquired pneumonia in adults: diagnosis and management [published correction appears in Am Fam Physician. 2017;95(7):414]. Am Fam Physician. 2016;94(9):698–706. Accessed September 15, 2020.

38. Htun TP, Sun Y, Chua HL, et al. Clinical features for diagnosis of pneumonia among adults in primary care setting: a systematic and meta-review. Sci Rep. 2019;9(1):7600.

39. Marchello CS, Ebell MH, Dale AP, et al. Signs and symptoms that rule out community-acquired pneumonia in outpatient adults: a systematic review and meta-analysis. J Am Board Fam Med. 2019;32(2):234–247.

40. Cao AMY, Choy JP, Mohanakrishnan LN, et al. Chest radiographs for acute lower respiratory tract infections. Cochrane Database Syst Rev. 2013;(12):CD009119.

41. Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005;294(15):1944–1956.

42. Ebell MH. Diagnosis of heart failure with reduced ejection fraction [Point-of-Care Guide]. Am Fam Physician. 2020;101(4):230–232. Accessed April 8, 2020.

43. Roalfe AK, Mant J, Doust JA, et al. Development and initial validation of a simple clinical decision tool to predict the presence of heart failure in primary care: the MICE (male, infarction, crepitations, edema) rule. Eur J Heart Fail. 2012;14(9):1000–1008.

44. West J, Goodacre S, Sampson F. The value of clinical features in the diagnosis of acute pulmonary embolism: systematic review and meta-analysis. QJM. 2007;100(12):763–769.

45. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98–107.

46. Singh B, Parsaik AK, Agarwal D, et al. Diagnostic accuracy of pulmonary embolism rule-out criteria: a systematic review and meta-analysis. Ann Emerg Med. 2012;59(6):517–520.e1–4.

47. Kline JA, Webb WB, Jones AE, et al. Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency department. Ann Emerg Med. 2004;44(5):490–502.

48. Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA. 2002;287(17):2262–2272.

49. Ohle R, Kareemi HK, Wells G, et al. Clinical examination for acute aortic dissection: a systematic review and meta-analysis. Acad Emerg Med. 2018;25(4):397–412.

50. McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87(3):177–182. Accessed September 15, 2020.

51. Cayley WE Jr. Diagnosing the cause of chest pain. Am Fam Physician. 2005;72(10):2012–2021. Accessed September 18, 2020.



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