Chest pain is responsible for approximately 1% of primary care encounters. Although most etiologies are benign and self-limited, some reflect underlying pathology associated with significant morbidity and mortality. The initial office evaluation for patients presenting with chest pain should include a comprehensive clinical history, physical examination, and 12-lead electrocardiography to identify those with potential cardiac etiologies. Patients with clinical evidence of acute coronary syndrome or other life-threatening causes of acute chest pain should be transported to the emergency department by emergency medical services. Pretest probability models such as the risk factor–weighted clinical likelihood are helpful for risk-stratifying outpatients with stable chest pain. Risk stratification tools such as the Marburg Heart Score and the International Working Group on Chest Pain in Primary Care rule are also used to stratify outpatients with stable chest pain and identify those at low risk of coronary artery disease who do not require additional testing. For patients with stable angina and intermediate or high risk of coronary artery disease, additional diagnostic testing with coronary computed tomography angiography or stress imaging is recommended. Clinical risk stratification tools such as the Wells criteria should be used to evaluate for pulmonary embolism. Patients with low or intermediate risk of pulmonary embolism should be evaluated with a d-dimer test, whereas those with high risk should have imaging.
Case 1. SB is a 60-year-old with a history of hypertension, hyperlipidemia, poorly controlled diabetes, class 3 obesity, tobacco use, gastroesophageal reflux disease, moderate depression, and generalized anxiety disorder. She presents with a several-week history of stable, intermittent left-sided chest pain. She denies any presyncopal symptoms and any history of heavy lifting, chest wall trauma, or recent travel.
Epidemiology
Approximately 1% of outpatient primary care visits are for chest pain, and its lifetime prevalence is 20% to 40%.1,2 However, only 1.5% of affected patients presenting to primary care will receive a diagnosis of acute myocardial infarction or unstable angina.3 In one study of patients presenting to primary care with chest pain, investigators found that 8.4% had life-threatening conditions and 0.7% of those with severe disease were missed by the physician.4
The most common causes of chest pain are musculoskeletal conditions (20%-50% of cases) and reflux esophagitis (13% of cases).1,5 Stable angina due to underlying coronary artery disease (CAD) accounts for 10% to 15% of cases.1,5 Other less common causes include pulmonary embolism (PE), pneumonia, congestive heart failure, aortic dissection, pericarditis, panic disorder, and herpes zoster. No definitive diagnosis is found in 15% of patients.2,5
Despite the low prevalence of acute myocardial infarction and unstable angina in ambulatory visits for chest pain, CAD is still the most common cause of death for people ages 65 and older in the United States.6 Chest pain remains a diagnostic challenge given the broad differential diagnosis and the potential for significant morbidity and mortality if CAD is missed. However, with appropriate evaluation and risk stratification, family physicians can effectively triage patients presenting with chest pain.
Initial Evaluation
PRESENTATION
History taking should focus on factors that distinguish emergent from nonemergent etiologies of chest pain, including acuity, severity, radiation, and associated symptoms such as dyspnea and lightheadedness. All patients should have vital signs evaluated immediately for hemodynamic instability, which indicates the need for emergent treatment. Hypoxia should be treated immediately with oxygen supplementation. Ideally, 12-lead electrocardiography (ECG) should be performed within 10 minutes of presentation.2
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