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 older adult 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'.)
Subscribers log in hereLiterature review current through: Nov 2017. | This topic last updated: Sep 25, 2017.References
- Svavarsdóttir AE, Jónasson MR, Gudmundsson GH, Fjeldsted K. Chest pain in family practice. Diagnosis and long-term outcome in a community setting. Can Fam Physician 1996; 42:1122.
- Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract 1994; 38:345.
- Bösner S, Becker A, Haasenritter J, et al. Chest pain in primary care: epidemiology and pre-work-up probabilities. Eur J Gen Pract 2009; 15:141.
- Ebell MH. Evaluation of chest pain in primary care patients. Am Fam Physician 2011; 83:603.
- von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med 2000; 160:2977.
- Pate JW, Walker WA, Cole FH Jr, et al. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989; 47:689.
- Fleet RP, Dupuis G, Marchand A, et al. Panic disorder, chest pain and coronary artery disease: literature review. Can J Cardiol 1994; 10:827.
- Bass C, Chambers JB, Kiff P, et al. Panic anxiety and hyperventilation in patients with chest pain: a controlled study. Q J Med 1988; 69:949.
- Evans DW, Lum LC. Hyperventilation: An important cause of pseudoangina. Lancet 1977; 1:155.
- Ros E, Armengol X, Grande L, et al. Chest pain at rest in patients with coronary artery disease. Myocardial ischemia, esophageal dysfunction, or panic disorder? Dig Dis Sci 1997; 42:1344.
- Ben Freedman S, Tennant CC. Panic disorder and coronary artery spasm. Med J Aust 1998; 168:376.
- Smoller JW, Pollack MH, Wassertheil-Smoller S, et al. Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women's Health Initiative Observational Study. Arch Gen Psychiatry 2007; 64:1153.
- Mehta NJ, Khan IA. Cardiac Munchausen syndrome. Chest 2002; 122:1649.
- McCauley J, Kern DE, Kolodner K, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123:737.
- Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 2005; 294:2623.
- Marcus GM, Cohen J, Varosy PD, et al. The utility of gestures in patients with chest discomfort. Am J Med 2007; 120:83.
- Verdon F, Burnand B, Herzig L, et al. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract 2007; 8:51.
- Davies HA, Jones DB, Rhodes J, Newcombe RG. Angina-like esophageal pain: differentiation from cardiac pain by history. J Clin Gastroenterol 1985; 7:477.
- Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. The rational clinical examination. Is this patient having a myocardial infarction? JAMA 1998; 280:1256.
- Berger JP, Buclin T, Haller E, et al. Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain. J Intern Med 1990; 227:165.
- Yelland MJ. Back, chest and abdominal pain. How good are spinal signs at identifying musculoskeletal causes of back, chest or abdominal pain? Aust Fam Physician 2001; 30:908.
- Chan S, Maurice AP, Davies SR, Walters DL. The use of gastrointestinal cocktail for differentiating gastro-oesophageal reflux disease and acute coronary syndrome in the emergency setting: a systematic review. Heart Lung Circ 2014; 23:913.
- Henrikson CA, Howell EE, Bush DE, et al. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med 2003; 139:979.
- Pryor DB, Harrell FE Jr, Lee KL, et al. Estimating the likelihood of significant coronary artery disease. Am J Med 1983; 75:771.
- Buntinx F, Knockaert D, Bruyninckx R, et al. Chest pain in general practice or in the hospital emergency department: is it the same? Fam Pract 2001; 18:586.
- Tierney WM, Roth BJ, Psaty B, et al. Predictors of myocardial infarction in emergency room patients. Crit Care Med 1985; 13:526.
- Sequist TD, Marshall R, Lampert S, et al. Missed opportunities in the primary care management of early acute ischemic heart disease. Arch Intern Med 2006; 166:2237.
- Norell M, Lythall D, Coghlan G, et al. Limited value of the resting electrocardiogram in assessing patients with recent onset chest pain: lessons from a chest pain clinic. Br Heart J 1992; 67:53.
- Law K, Elley R, Tietjens J, Mann S. Troponin testing for chest pain in primary healthcare: a survey of its use by general practitioners in New Zealand. N Z Med J 2006; 119:U2082.
- Wilhelmsen L, Rosengren A, Hagman M, Lappas G. "Nonspecific" chest pain associated with high long-term mortality: results from the primary prevention study in Göteborg, Sweden. Clin Cardiol 1998; 21:477.
- Ruigómez A, Rodríguez LA, Wallander MA, et al. Chest pain in general practice: incidence, comorbidity and mortality. Fam Pract 2006; 23:167.
- Robinson JG, Wallace R, Limacher M, et al. Elderly women diagnosed with nonspecific chest pain may be at increased cardiovascular risk. J Womens Health (Larchmt) 2006; 15:1151.
- Geraldine McMahon C, Yates DW, Hollis S. Unexpected mortality in patients discharged from the emergency department following an episode of nontraumatic chest pain. Eur J Emerg Med 2008; 15:3.
- Yelland M, Cayley WE Jr, Vach W. An algorithm for the diagnosis and management of chest pain in primary care. Med Clin North Am 2010; 94:349.
- Wang WH, Huang JQ, Zheng GF, et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis. Arch Intern Med 2005; 165:1222.
- Borzecki AM, Pedrosa MC, Prashker MJ. Should noncardiac chest pain be treated empirically? A cost-effectiveness analysis. Arch Intern Med 2000; 160:844.
- Wertli MM, Ruchti KB, Steurer J, Held U. Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis. BMC Med 2013; 11:239.
- Stochkendahl MJ, Christensen HW, Vach W, et al. Chiropractic treatment vs self-management in patients with acute chest pain: a randomized controlled trial of patients without acute coronary syndrome. J Manipulative Physiol Ther 2012; 35:7.
- - Myocardial ischemia
- - Nonischemic cardiac causes
- - Description of chest pain
- - Associated symptoms
- - Other medical history
- Physical examination
- Other diagnostic studies
- DIAGNOSTIC APPROACH
- Life-threatening etiology
- Evaluation for stable myocardial ischemia
- Evaluation for other etiologies
- - Nonischemic cardiac disease
- - Pulmonary disease
- - Gastrointestinal disease
- - Musculoskeletal disease
- - Psychiatric disease
- - Other conditions
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS