INTRODUCTION

The patient who describes chest pain to the primary care physician represents an immediate challenge. The symptom is usually of benign etiology, but rarely it may portend imminent catastrophe. Although standard textbooks of medicine often emphasize the high-risk nature of chest pain, non-life-threatening etiologies, which may be functionally disabling, are much more common in the primary care setting and require a cost-effective approach to diagnosis [1-3]. The correct diagnosis is most often derived from a vigilantly obtained, detailed history (pain description; associated symptoms; and in some cases disease risk factors) that is supported by specific physical findings, an electrocardiogram, and/or chest x-ray.

Importantly, the prevalence of chest pain etiologies varies according to the population studied [4]. The causes of chest pain that are most common in primary care practice and the diagnostic approach in the office for chest pain of uncertain etiology are reviewed here. A more complete discussion of the differential diagnosis of chest pain is found separately. (See "Differential diagnosis of chest pain in adults".)

EPIDEMIOLOGY IN PRIMARY CARE POPULATIONS

A prospective study of 399 episodes of chest pain in patients seen in multiple outpatient centers over a one-year period noted the following prevalences of various causes of chest pain (table 1) [5]:

• Approximately 60 percent of chest pain diagnoses were not "organic" in origin (ie, not due to cardiac, gastrointestinal, or pulmonary disease).
• Musculoskeletal chest pain accounted for 36 percent of all diagnoses (of which costochondritis accounted for 13 percent) followed by reflux esophagitis (13 percent).
• Stable angina pectoris was responsible for 11 percent of chest pain episodes; unstable angina or myocardial infarction occurred in only 1.5 percent. Nevertheless, most of the ancillary diagnostic testing used was directed toward finding or excluding a cause of coronary disease.

These observations are consistent with other reports of the frequency of etiologies of chest pain in primary care practice [1,2,4,6,7].