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Am Fam Physician. 2020;102(12):721-727

Related letter: Previous ECG Criteria (Including STEMI Criteria) Overlook Too Many Acute MIs Due to Acute Coronary Occlusion

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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

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 BLarge 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 BSmaller 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 CClinical 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 BUnblinded 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 CClinical 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 CClinical 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 BValidation of a clinical prediction rule
RecommendationSponsoring organization
Do not use coronary computed tomography angiography in high-risk patients presenting to the emergency department with acute chest pain.Society of Cardiovascular Computed Tomography
Do not perform cardiac magnetic resonance imaging in patients with acute chest pain and high probability of coronary artery disease.Society for Cardiovascular Magnetic Resonance

Initial Evaluation

The first decision point for most physicians is to determine whether the patient needs immediate referral to the emergency department for further testing to determine whether the chest pain is an acute coronary syndrome (ACS) caused by coronary ischemia.7 ACS is a clinical diagnosis that includes unstable angina, ST segment elevation myocardial infarction, and non–ST segment elevation myocardial infarction. Definitions of chest pain have evolved over time. Typical chest pain or angina is a deep, poorly localized chest or arm discomfort (pain or pressure) associated with physical exertion or emotional stress and relieved with rest or sublingual nitroglycerin within five minutes.8 Unstable angina is new-onset angina, angina at rest, or angina that becomes more frequent, severe, or prolonged.9 Acute myocardial infarction is myocardial injury resulting in elevated cardiac biomarkers in the setting of acute ischemia caused by ST segment elevation myocardial infarction or non–ST segment elevation myocardial infarction.10 The impression of chest pain is often determined by a combination of clinical symptoms at the time of presentation, physical examination, initial electrocardiography (ECG), and risk factors for ACS.11 Patients often do not use the term pain to describe their symptoms but frequently use other terms such as pressure, aching, discomfort, tightness, squeezing, or indigestion.12

A meta-analysis of studies that evaluated the role of previous chest pain in diagnosing ACS concluded that chest pain that is pleuritic, positional, or reproducible with palpation and not related to exertion is low risk for ACS. Pain that is described as pressure (similar to that of prior myocardial infarction), worse than prior anginal pain, associated with exertion, accompanied by nausea or diaphoresis, and/or radiates to one or both arms/shoulders is higher risk for ACS.13

Although individual characteristics generally do not support or rule out a diagnosis, a combination of these may increase diagnostic accuracy.14 The combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease (CAD) as the cause of chest pain.15 Table 1 outlines updated predicted pretest probabilities of CAD in patients with chest pain based on these three factors.15 U.S. guidelines recommend that patients with a probability of less than 5% be classified as low risk and not undergo further testing.16 Those with a probability greater than 70% should undergo invasive angiography, and those with a probability of 5% to 70% should undergo noninvasive testing.16 European guidelines use cutoffs of 15% and 85%, respectively.15

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