Evaluation of the adult with chest pain in the emergency department
- Judd E Hollander, MD
Judd E Hollander, MD
- Professor and Vice Chair Department of Emergency Medicine
- Thomas Jefferson University
- Maureen Chase, MD, MPH
Maureen Chase, MD, MPH
- Assistant Professor of Emergency Medicine
- Harvard Medical School
Chest pain accounts for approximately six million annual visits to emergency departments (ED) in the United States, making chest pain the second most common complaint . Patients present with a spectrum of signs and symptoms reflecting the many potential etiologies of chest pain. Diseases of the heart, aorta, lungs, esophagus, stomach, mediastinum, pleura, and abdominal viscera may all cause chest discomfort.
Clinicians in the ED focus on the immediate recognition and exclusion of life-threatening causes of chest pain. Patients with life-threatening etiologies for chest pain may appear deceptively well, manifesting neither vital sign nor physical examination abnormalities.
This topic review will discuss life-threatening and common causes of chest pain, and provide an approach to the evaluation of chest pain patients in the ED. Detailed discussions of specific causes of chest pain, including the management of a suspected acute coronary syndrome in the ED are found elsewhere. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department" and "Overview of acute pulmonary embolism in adults" and "Management of aortic dissection" and "Primary spontaneous pneumothorax in adults" and "Secondary spontaneous pneumothorax in adults" and "Cardiac tamponade" and "Boerhaave syndrome: Effort rupture of the esophagus".)
Life-threatening conditions — Causes of chest pain that pose an immediate threat to life include:
●Acute coronary syndrome
- McCaig, L, Burt, C. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. In: Advance Data from Vital and Health Statistics. Centers for disease control and prevention, Atlanta, GA 2005.
- Launbjerg J, Fruergaard P, Hesse B, et al. Long-term risk of death, cardiac events and recurrent chest pain in patients with acute chest pain of different origin. Cardiology 1996; 87:60.
- Lindsell CJ, Anantharaman V, Diercks D, et al. The Internet Tracking Registry of Acute Coronary Syndromes (i*trACS): a multicenter registry of patients with suspicion of acute coronary syndromes reported using the standardized reporting guidelines for emergency department chest pain studies. Ann Emerg Med 2006; 48:666.
- Estrera AS, Landay MJ, Grisham JM, et al. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983; 157:545.
- Burnett CM, Rosemurgy AS, Pfeiffer EA. Life-threatening acute posterior mediastinitis due to esophageal perforation. Ann Thorac Surg 1990; 49:979.
- Sancho LM, Minamoto H, Fernandez A, et al. Descending necrotizing mediastinitis: a retrospective surgical experience. Eur J Cardiothorac Surg 1999; 16:200.
- Makeieff M, Gresillon N, Berthet JP, et al. Management of descending necrotizing mediastinitis. Laryngoscope 2004; 114:772.
- Gupta M, Tabas JA, Kohn MA. Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med 2002; 40:180.
- Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000; 342:1163.
- Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283:897.
- Ringstrom E, Freedman J. Approach to undifferentiated chest pain in the emergency department: a review of recent medical literature and published practice guidelines. Mt Sinai J Med 2006; 73:499.
- Jagminas L, Silverman RA. Boerhaave's syndrome presenting with abdominal pain and right hydropneumothorax. Am J Emerg Med 1996; 14:53.
- Brauer RB, Liebermann-Meffert D, Stein HJ, et al. Boerhaave's syndrome: analysis of the literature and report of 18 new cases. Dis Esophagus 1997; 10:64.
- Shry EA, Dacus J, Van De Graaff E, et al. Usefulness of the response to sublingual nitroglycerin as a predictor of ischemic chest pain in the emergency department. Am J Cardiol 2002; 90:1264.
- Grailey K, Glasziou PP. Diagnostic accuracy of nitroglycerine as a 'test of treatment' for cardiac chest pain: a systematic review. Emerg Med J 2012; 29:173.
- Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA 2002; 287:2262.
- Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad Emerg Med 2002; 9:203.
- Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 2002; 122:311.
- Jayes RL Jr, Beshansky JR, D'Agostino RB, Selker HP. Do patients' coronary risk factor reports predict acute cardiac ischemia in the emergency department? A multicenter study. J Clin Epidemiol 1992; 45:621.
- Joseph J, Sahn SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med 1996; 100:164.
- Henry M, Arnold T, Harvey J, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003; 58 Suppl 2:ii39.
- Papanicolaou MN, Califf RM, Hlatky MA, et al. Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol 1986; 58:1181.
- Pitts WR, Lange RA, Cigarroa JE, Hillis LD. Repeat coronary angiography in patients with chest pain and previously normal coronary angiogram. Am J Cardiol 1997; 80:1086.
- Brush JE Jr, Brand DA, Acampora D, et al. Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction. N Engl J Med 1985; 312:1137.
- Slater DK, Hlatky MA, Mark DB, et al. Outcome in suspected acute myocardial infarction with normal or minimally abnormal admission electrocardiographic findings. Am J Cardiol 1987; 60:766.
- Lee TH, Cook EF, Weisberg M, et al. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 1985; 145:65.
- Selker HP, Zalenski RJ, Antman EM, et al. An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: a report from a National Heart Attack Alert Program Working Group. Ann Emerg Med 1997; 29:13.
- Hathaway WR, Peterson ED, Wagner GS, et al. Prognostic significance of the initial electrocardiogram in patients with acute myocardial infarction. GUSTO-I Investigators. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries. JAMA 1998; 279:387.
- Rodger M, Makropoulos D, Turek M, et al. Diagnostic value of the electrocardiogram in suspected pulmonary embolism. Am J Cardiol 2000; 86:807.
- Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002; 347:161.
- von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med 2000; 160:2977.
- Ayaram D, Bellolio MF, Murad MH, et al. Triple rule out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med 2013; In Press.
- Chase M, Robey JL, Zogby KE, et al. Prospective validation of the Thrombolysis in Myocardial Infarction Risk Score in the emergency department chest pain population. Ann Emerg Med 2006; 48:252.
- Lee B, Chang AM, Matsuura AC, et al. Comparison of cardiac risk scores in ED patients with potential acute coronary syndrome. Crit Pathw Cardiol 2011; 10:64.
- Meyer MC, Mooney RP, Sekera AK. A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing. Ann Emerg Med 2006; 47:427.
- Walker NJ, Sites FD, Shofer FS, Hollander JE. Characteristics and outcomes of young adults who present to the emergency department with chest pain. Acad Emerg Med 2001; 8:703.
- DIFFERENTIAL DIAGNOSIS
- Life-threatening conditions
- Common conditions
- General approach
- Onset of pain
- Pain quality and location
- Associated symptoms
- Risk factors
- Prior testing
- PHYSICAL EXAMINATION
- ANCILLARY STUDIES
- Laboratory studies
- Chest radiograph
- Other imaging
- APPROACH TO DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS