Outpatient evaluation of the adult with chest pain
- Michael J Yelland, MBBS, PhD, FRACGP, FAFMM
Michael J Yelland, MBBS, PhD, FRACGP, FAFMM
- Associate Professor in Primary Health Care
- Griffith University, Queensland Australia
Patients who present to the office with chest pain are a diagnostic challenge given the wide array of possible etiologies. However, the diagnosis can often be derived from a history, physical examination, and specific ancillary studies.
This topic reviews those causes of chest pain that are most common in primary care practice and the diagnostic approach to chest pain. The evaluation of chest pain in the emergency department is discussed elsewhere. (See "Evaluation of the adult with chest pain in the emergency department".)
The etiologies of chest pain range from life-threatening conditions to those that are relatively benign. The most common causes of chest pain in outpatients are musculoskeletal and gastrointestinal conditions. Studies have estimated that approximately one-third to one-half of patients have musculoskeletal chest pain, 10 to 20 percent have a gastrointestinal causes, 10 percent have stable angina, 5 percent have respiratory conditions, and approximately 2 to 4 percent have acute myocardial ischemia (including myocardial infarction) [1-4].
Myocardial ischemia — Angina pectoris, or angina, describes chest pain attributable to myocardial ischemia. Classic symptoms of stable angina include a pressure, heaviness, tightness, or constriction in the center or left of the chest that is precipitated by exertion and relieved by rest. Other associated symptoms include provocation with emotional stress or cold, radiation (to the neck, jaw, and shoulder), dyspnea, nausea and vomiting, diaphoresis, presyncope, or palpitations. (See "Angina pectoris: Chest pain caused by myocardial ischemia".)
The clinical presentation of myocardial ischemia varies by population. Women, diabetics, and elderly patients are more likely to present without chest pain but have symptoms of dyspnea, weakness, nausea and vomiting, palpitations, or syncope. Compared with older patients, younger patients are less likely to have stable angina and have a higher incidence of acute coronary syndrome (ACS). (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on 'Atypical symptoms' and "Clinical features and diagnosis of coronary heart disease in women", section on 'Clinical presentation' and "Prevalence of and risk factors for coronary heart disease in diabetes mellitus", section on 'Silent ischemia and infarction' and "Coronary heart disease and myocardial infarction in young men and women", section on 'Clinical presentation'.)
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- - Myocardial ischemia
- - Nonischemic cardiac causes
- - Description
- - Associated symptoms
- - Other medical history
- Physical examination
- Other studies
- DIAGNOSTIC APPROACH
- Life-threatening etiology
- Evaluation for stable myocardial ischemia
- Evaluation for other etiologies
- - Suspected nonischemic cardiac etiologies
- - Suspected gastrointestinal etiology
- - Suspected musculoskeletal etiology
- - Suspected pulmonary etiology
- - Suspected psychiatric etiology
- - Other
- - Referral
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS