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Outpatient evaluation of the adult with chest pain

Outpatient evaluation of the adult with chest pain
Author:
Hiten Patel, MD, MPH
Section Editor:
Mark D Aronson, MD
Deputy Editor:
Sara Swenson, MD
Literature review current through: Jan 2024.
This topic last updated: Dec 06, 2023.

INTRODUCTION — Patients who present to the office with chest pain are a diagnostic challenge given the wide array of possible etiologies, including a potentially life-threatening condition. Approximately 1 percent of all ambulatory visits in primary care are for chest pain [1]. Cardiac disease is the leading cause of death in the United States, yet only 2 to 4 percent of patients presenting to a primary care office with chest pain will have unstable angina or an acute myocardial infarction [2-4]. The most common causes of chest pain in the primary care population are chest wall pain (20 to 50 percent), reflux esophagitis (10 to 20 percent), and costochondritis (13 percent).

This topic reviews those causes of chest pain that are most common in primary care practice and the office-based 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".)

DIFFERENTIAL DIAGNOSIS — The causes of chest pain range from life-threatening conditions to those that are relatively benign.

Life-threatening conditions — Patients in whom there is concern for a life-threatening condition should be referred to the emergency department by ambulance. These conditions include (not listed in any order of importance):

Acute coronary syndrome – Patients with acute coronary syndrome (ACS) have anginal symptoms at rest, new-onset angina, or progressive angina (more frequent, longer in duration, or occurring with less exertion than previously). Women, individuals with diabetes, and younger adult patients may present without classic chest pain but have symptoms of dyspnea, weakness, nausea, vomiting, palpitations, or syncope. An electrocardiogram (ECG) should be performed, and prior to transfer to the emergency department they should also be given aspirin (162 to 325 mg) and appropriate initial interventions (eg, sublingual nitroglycerin), if available. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department".)

Aortic dissection – Aortic dissection is rare but may be a surgical emergency. Patients with acute aortic dissection typically present with acute chest and back pain that is sudden onset, severe, sharp, and may have a ripping or tearing quality [5]. Pain can radiate anywhere in the chest or into the abdomen. (See "Clinical features and diagnosis of acute aortic dissection", section on 'Symptoms and signs'.)

Thoracic aortic aneurysm – Individuals with a rapidly expanding thoracic aortic aneurysm can present with severe chest, back, or abdominal pain as well as other symptoms related to direct compression of thoracic structures by the aneurysm. Aneurysmal rupture is a surgical emergency that causes severe chest pain with accompanying hypotension or shock. (See "Clinical manifestations and diagnosis of thoracic aortic aneurysm", section on 'Symptomatic TAA'.)

Pulmonary embolism – The most common symptoms of pulmonary embolism include dyspnea, pleuritic chest pain, cough, and symptoms of deep venous thrombosis. Risk factors that may predispose to thromboembolic disease are listed in the table (table 1). In addition, the Wells score is a useful tool for calculating the probability of pulmonary embolism (calculator 1). (See "Epidemiology and pathogenesis of acute pulmonary embolism in adults", section on 'Clinical presentation, evaluation, and diagnosis'.)

Tension pneumothorax – Patients with spontaneous pneumothorax present with sudden onset of pleuritic chest pain and dyspnea. Evidence of labored breathing, or accessory muscle use suggest a sizeable pneumothorax. Hemodynamic compromise (eg, tachycardia, hypotension) is an ominous sign and suggests a tension pneumothorax and/or impending cardiopulmonary collapse. (See "Evaluation of the adult with chest pain in the emergency department", section on 'Life-threatening conditions' and "Pneumothorax in adults: Epidemiology and etiology".)

Esophageal rupture, perforation – Spontaneous perforation of the esophagus (Boerhaave syndrome) caused by straining or vomiting presents as excruciating retrosternal chest pain [6]. Crepitus may be palpated on the chest wall due to subcutaneous emphysema. (See "Boerhaave syndrome: Effort rupture of the esophagus", section on 'Clinical features'.)

Cardiac tamponade – In a patient with a pericardial effusion, the development of cardiac tamponade can be life-threatening. Symptoms are sudden in onset and include chest pain and dyspnea. Vital sign changes include hypotension and tachypnea. The jugular venous pressure is markedly elevated and may be associated with venous distension in the forehead and scalp. The heart sounds are often muted. (See "Pericardial effusion: Approach to diagnosis", section on 'Diagnostic approach'.)

Cardiac arrhythmias – Some potentially life-threatening arrhythmias, such as ventricular tachycardia or third-degree (complete) heart block, can present with chest pain. In individuals with ventricular tachycardia, chest pain often accompanies palpitations, dyspnea, or presyncope/syncope. Patients with third-degree heart block commonly note dyspnea or fatigue, but can also experience chest pain.

Other etiologies — Other etiologies of chest pain are listed in the table (table 2), with a synopsis of selected conditions below. Most can be handled in the primary care office, although some patients with certain conditions (eg, pericarditis, heart failure, stress cardiomyopathy) may require hospitalization. The following are not listed in any particular order of incidence or importance.

Cardiac conditions

Stable myocardial ischemia — Angina pectoris, or angina, describes chest pain attributable to myocardial ischemia. It is considered stable when provoked by conditions associated with increased oxygen demand or decreased oxygen supply (table 3), and unstable when it occurs without an obvious trigger. Causes of myocardial ischemia are discussed in detail separately. (See "Approach to the patient with suspected angina pectoris", section on 'Conditions causing or worsening angina'.)

The classic clinical presentation of myocardial ischemia includes chest discomfort that is worse with exertion and improves with nitroglycerine. Symptoms of myocardial ischemia vary by population. Women, individuals with diabetes, and younger adult patients are more likely to present without chest pain but have symptoms of dyspnea, weakness, nausea and vomiting, palpitations, or syncope.

(See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on 'Atypical presentations'.)

(See "Prevalence of and risk factors for coronary heart disease in patients with diabetes mellitus", section on 'Silent ischemia and infarction'.)

(See "Coronary artery disease and myocardial infarction in young people", section on 'Clinical manifestations'.)

Other cardiac causes — Nonischemic cardiac etiologies of chest pain include:

Heart failure – Patients with acute decompensated heart failure may present with chest discomfort, usually along with progressive dyspnea, cough, fatigue, and peripheral edema. (See "Approach to diagnosis and evaluation of acute decompensated heart failure in adults", section on 'Clinical manifestations'.)

Pericarditis/myopericarditis – Acute pericarditis refers to inflammation of the pericardial sac. Etiologies include infection, medications, autoimmune disorders, uremia, and malignancy. The term myopericarditis indicates a primarily pericarditic syndrome with minor myocardial involvement. Key symptoms include sharp, pleuritic chest pain which is decreased by leaning forward from a seated position, and radiates to the trapezius ridge. Pericarditis has characteristic ECG changes of diffuse ST elevations and PR depressions. (See "Acute pericarditis: Clinical presentation and diagnosis", section on 'Clinical features' and "Myopericarditis".)

Myocarditis – Acute myocarditis refers to inflammation of the cardiac muscle, due to infectious and noninfectious causes. Symptoms are similar to those of pericarditis described above. (See "Clinical manifestations and diagnosis of myocarditis in adults".)

Stress cardiomyopathy – Stress (takotsubo) cardiomyopathy is a syndrome characterized by transient regional systolic dysfunction of the left ventricle that often occurs in the setting of physical or emotional stress or critical illness. Symptoms, including substernal chest pain, are similar to those of acute myocardial infarction. (See "Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy", section on 'Pathogenesis' and "Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy", section on 'Clinical manifestations'.)

Aortic valve disease – Symptoms of aortic stenosis include exertional angina, exertional dyspnea, and decreased exercise tolerance, as well as exertional presyncope or syncope. (See "Clinical manifestations and diagnosis of aortic stenosis in adults", section on 'Symptoms'.)

Mitral valve disease – Patients with mitral stenosis infrequently experience chest pain which resembles angina, due to pulmonary hypertension and right ventricular hypertrophy. Symptoms of mitral stenosis typically include slowly progressive exertional dyspnea. (See "Rheumatic mitral stenosis: Clinical manifestations and diagnosis", section on 'Chest pain'.)

Patients with mitral valve prolapse may have chest pain, but it is generally mild and not typical for angina. (See "Mitral valve prolapse: Clinical manifestations and diagnosis", section on 'MVP syndrome'.)

Pulmonary — Patients with pulmonary etiologies for chest pain generally also have respiratory symptoms and may be hypoxemic.

Pneumothorax – A primary spontaneous pneumothorax usually occurs without a precipitating event in young patients (typically in their twenties) with no clinical lung disease. A secondary spontaneous pneumothorax occurs as a complication of underlying lung disease (eg, chronic obstructive pulmonary disease [COPD]). Typically symptoms include sudden onset of dyspnea and pleuritic chest pain, usually unilateral. (See "Clinical presentation and diagnosis of pneumothorax", section on 'Clinical presentation'.)

Hemodynamic instability suggests a tension pneumothorax, which can be life-threatening and requires prompt transfer to the emergency department. (See "Evaluation of the adult with chest pain in the emergency department", section on 'Life-threatening conditions'.)

Pneumonia – Patients with pneumonia may have chest pain, which is often pleuritic. They also have fever and productive cough. (See "Clinical evaluation and diagnostic testing for community-acquired pneumonia in adults", section on 'Clinical evaluation'.)

Malignancy – Patients with lung cancer may complain of chest pain, typically on the same side as the primary tumor. Other symptoms can include cough, hemoptysis, and dyspnea. (See "Clinical manifestations of lung cancer", section on 'Chest pain'.)

Asthma and COPD – Asthma and COPD exacerbations are often associated with chest tightness along with dyspnea. Triggers for exacerbation (eg, pneumonia) may also cause chest pain. (See "Asthma in adolescents and adults: Evaluation and diagnosis", section on 'Clinical features' and "Chronic obstructive pulmonary disease: Diagnosis and staging", section on 'Symptoms and pattern of onset'.)

Pleuritis – Pleuritis is an inflammation of the lung pleura and causes pleuritic chest pain. Causes include autoimmune diseases (eg, systemic lupus erythematosus) and drugs (eg, procainamide, hydralazine, isoniazid). Associated systemic signs and symptoms of autoimmune disease include fever, rash, arthralgias, and constitutional symptoms. (See "Pulmonary manifestations of systemic lupus erythematosus in adults", section on 'Pleural disease' and "Overview of pleuropulmonary diseases associated with rheumatoid arthritis", section on 'Pleural disease' and "Drug-induced lupus", section on 'Clinical spectrum of drug-induced lupus'.)

Sarcoidosis – Chest pain is a common manifestation of pulmonary sarcoidosis, most commonly in association with cough and dyspnea (see "Clinical manifestations and diagnosis of sarcoidosis"). Sarcoidosis can also cause arrhythmias [7].

Acute chest syndrome – Patients with sickle cell anemia may present with chest pain in the setting of acute chest syndrome. These patients will also have an infiltrate on chest radiograph; other symptoms include fever, tachypnea, cough, and decreased oxygen saturation. (See "Acute chest syndrome (ACS) in sickle cell disease (adults and children)", section on 'Clinical features'.)

Pulmonary hypertension – Patients with pulmonary hypertension may have exertional chest pain in addition to exertional dyspnea and syncope. (See "Clinical features and diagnosis of pulmonary hypertension of unclear etiology in adults", section on 'Clinical manifestations'.)

Gastrointestinal — Gastroesophageal reflux disease (GERD) is a common cause of noncardiac chest pain.

GERD – Chest pain due to GERD can mimic angina pectoris and may be described as squeezing or burning, located substernally and radiating to the back, neck, jaw, or arms. It can last minutes to hours and resolves spontaneously or with antacids. It may occur after meals, awaken patients from sleep, and be exacerbated by emotional stress. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)

Peptic ulcer disease – Symptomatic peptic ulcers commonly present with epigastric pain or food-provoked epigastric discomfort and fullness, early satiety, and nausea. A perforated peptic ulcer can cause acute, severe chest or abdominal pain. (See "Peptic ulcer disease: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

Esophageal motility disorders – Esophageal motility disorders can cause chest pain. Signs and symptoms of esophageal motility disorders include squeezing or spasming substernal chest pain that occurs after food intake. Additionally, patients may have dysphagia or symptoms of heartburn. (See "Evaluation of the adult with chest pain of esophageal origin".)

Esophagitis – Patients with esophagitis may present with sudden-onset retrosternal chest pain with odynophagia. Causes of esophagitis include candidiasis, cytomegalovirus (as a complication of acquired immunodeficiency syndrome [AIDS]), medication-induced ("pill esophagitis"), and radiation injury. (See "Pill esophagitis", section on 'Clinical manifestations' and "Esophageal candidiasis in adults" and "AIDS-related cytomegalovirus gastrointestinal disease" and "Overview of gastrointestinal toxicity of radiation therapy".)

Eosinophilic esophagitis – Eosinophilic esophagitis may mimic GERD in its presentation. Patients often present heartburn, dysphagia, or chest pain that may be resistant to antacid therapy. (See "Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)", section on 'Clinical manifestations in adults'.)

Other – Hiatus hernias may cause chest pain in addition to reflux symptoms. Acute cholecystitis, biliary colic, and pancreatitis may have pain that involves the chest. (See "Hiatus hernia", section on 'Clinical features' and "Acute calculous cholecystitis: Clinical features and diagnosis" and "Clinical manifestations and diagnosis of acute pancreatitis" and "Clinical manifestations and diagnosis of acute pancreatitis", section on 'Clinical features'.)

Musculoskeletal — Musculoskeletal etiologies are common in patients who present to the primary care clinician's office with chest pain. (See "Major causes of musculoskeletal chest pain in adults".)

Isolated musculoskeletal chest pain syndrome – Patients with isolated musculoskeletal chest pain syndromes have local or regional chest tenderness (table 4) without cardiopulmonary symptoms. The most common are costosternal (costochondritis) and lower rib pain syndromes. (See "Major causes of musculoskeletal chest pain in adults", section on 'Isolated musculoskeletal chest pain syndromes'.)

Rheumatic diseases – Rheumatic diseases can be associated with musculoskeletal chest wall pain, but patients generally have other symptoms of rheumatic disease. Pain may be from increased sensitivity to ordinarily nonpainful stimuli (eg, in fibromyalgia) or involvement of thoracic or costochondral joints (eg, in rheumatoid arthritis or ankylosing spondylitis). Common rheumatologic causes of chest pain are presented in the table (table 5). (See "Major causes of musculoskeletal chest pain in adults", section on 'Rheumatic diseases causing musculoskeletal chest wall pain'.)

Rib pain – Rib fractures are associated with chest wall pain that is localized and reproducible with palpation. Patients often describe an associated injury, though some may occur without trauma (eg, osteoporosis). (See "Initial evaluation and management of rib fractures", section on 'Clinical Features'.)

A variety of systemic disorders can also lead to chest wall pain from rib pathology. These are uncommon but include rib sarcoma, multiple myeloma, and metastatic breast or lung cancer. (See "Major causes of musculoskeletal chest pain in adults", section on 'Nonrheumatic systemic causes of chest wall pain'.)

Trauma – Patients can have a variety of injuries from trauma that cause musculoskeletal chest pain. These are discussed separately. (See "Initial evaluation and management of chest wall trauma in adults", section on 'Management of specific injuries'.)

Psychiatric — Chest pain is a common symptom among patients with psychiatric disorders.

Panic attack/disorder – Panic attacks typically present with spontaneous, discrete episodes of intense fear that begin abruptly and last for several minutes to an hour. In panic disorder, patients experience recurrent panic attacks, with worry about future attacks or avoidance of behaviors related to attacks. One in four people with a panic attack will have chest pain and shortness of breath [8]. Additional symptoms of panic disorder include palpitations, nausea, sweating, dizziness, and a sense of impending doom. Panic disorder may be present in 30 percent or more of patients with chest pain who have no or minimal coronary heart disease (CHD) [9]. Hyperventilation during a panic attack can result in nonanginal chest pain and occasionally ECG changes, particularly nonspecific ST and T wave abnormalities [10,11]. (See "Panic disorder in adults: Epidemiology, clinical manifestations, and diagnosis".)

Patients with psychiatric disorders may develop or have coexisting CHD, and in such patients, ischemia may occur during a panic attack [9,12,13]. In a subgroup analysis of the Women's Health Initiative Observational Study, panic disorder was an independent risk factor for CHD in postmenopausal women [14].

Other – Other psychiatric etiologies of chest pain include depression, somatization, or factitious disorder. (See "Unipolar minor depression in adults: Epidemiology, clinical presentation, and diagnosis", section on 'Symptoms' and "Somatic symptom disorder: Epidemiology and clinical presentation" and "Factitious disorder imposed on self (Munchausen syndrome)".)

Drugs of abuse

Cocaine – Myocardial ischemia is the most common cardiac condition associated with cocaine use and is usually due to coronary artery spasm [15]. Other cardiac complications of cocaine use include aortic dissection, coronary artery aneurysm, myocarditis and cardiomyopathy, and arrhythmias. (See "Clinical manifestations, diagnosis, and management of the cardiovascular complications of cocaine abuse".)

The pulmonary complications of cocaine use can also cause chest pain but are associated with respiratory symptoms. These include acute pulmonary toxicity ("crack lung"), acute eosinophilic pneumonia, pneumothorax and pneumomediastinum, and pulmonary vascular disease. (See "Pulmonary complications of cocaine use".)

Methamphetamine – Methamphetamine intoxication may mimic cocaine intoxication and cause similar cardiac complications. (See "Methamphetamine: Acute intoxication", section on 'Examination findings associated with intoxication and complications'.)

Referred pain — Chest wall pain may be referred from painful disorders in visceral or somatic structures sharing the same spinal cord segments. The pain is perceived in the corresponding dermatomes and myotomes. For example, referred pain can come from abdominal organs, cervical disc disease, or from the ligaments, muscles, and periosteum of the cervical and thoracic spines. Acute cholecystitis and pancreatitis may have referred pain that involves the chest. (See "Acute calculous cholecystitis: Clinical features and diagnosis" and "Clinical manifestations and diagnosis of acute pancreatitis" and "Clinical manifestations and diagnosis of acute pancreatitis", section on 'Clinical features'.)

Herpes zoster — Chest pain, especially in older adults, may be the presenting symptom of herpes zoster, preceding the characteristic rash usually by two to three days. Dysesthesia is usually present in the affected dermatome. Postherpetic neuralgia may also cause chest pain. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on 'Clinical manifestations' and "Postherpetic neuralgia", section on 'Clinical manifestations'.)

Intimate partner violence — Patients suffering from intimate partner violence may have chest pain as a physical symptom that is due to trauma or associated psychiatric conditions (eg, panic disorder). In a community-based population of 1900 primary care patients, chest pain was one of the physical symptoms associated with current domestic violence [16]. (See "Intimate partner violence: Diagnosis and screening", section on 'Common presenting concerns'.)

DIAGNOSTIC APPROACH — The following discussion presents a diagnostic approach to patients who present to the office with chest pain. The initial assessment should identify patients with life-threatening conditions who need to be transferred to the emergency department. The evaluation should then proceed to a thorough history and physical examination to assess the probability of specific causes of chest pain and determine the need for further testing.

Initial triage

All patients should have vital signs and oxygen saturation measurement.

Patients with unstable vital signs should be evaluated urgently by a clinician.

If symptoms are concerning for aortic dissection (acute chest and back pain that is severe, sharp, with a ripping or tearing quality), blood pressure should be obtained in both arms.

If pericarditis is suspected, based on pleuritic chest pain and relief when sitting forward, pulsus paradoxus should be evaluated and an electrocardiogram performed. (See 'Nonischemic cardiac disease' below.)

Patients who have unstable vital signs or symptoms of life-threatening conditions should be sent to the emergency department by ambulance.

Symptoms of life-threatening conditions include:

Anginal symptoms at rest, new onset angina, or angina that is unpredictable or progressive (more frequent, longer in duration, or occurring with less exertion than previously). These symptoms are consistent with acute coronary syndrome (ACS).

Acute chest and back pain that is severe and sharp and has a ripping or tearing quality, consistent with aortic dissection or rupture.

Pleuritic chest pain associated with dyspnea, tachycardia, hypotension, muffled heart sounds and/or elevated jugular venous pressure and raise concern for cardiac tamponade.

Pleuritic chest pain, cough, and symptoms of deep venous thrombosis (leg swelling, pain), consistent with pulmonary embolism

Sudden onset of pleuritic chest pain and dyspnea with signs of hemodynamic instability, suggestive of a tension pneumothorax.

Excruciating retrosternal chest pain with a history of vomiting, consistent with Boerhaave syndrome.

History and physical examination — A thorough history and a physical examination are required. A detailed history for evaluating a patient with chest pain is available elsewhere. (See "Evaluation of the adult with chest pain in the emergency department", section on 'History'.)

Indications for electrocardiogram — We obtain an ECG for all patients with new-onset chest pain or pain that is different than previous episodes, even if associated with an established noncardiac etiology, unless there is an obvious cause for the pain (eg, pneumonia or suspected pneumothorax) and/or the patient is low risk for cardiovascular disease.

The ECG is most helpful in the evaluation of patients with suspected myocardial ischemia.

Patients with an initial ECG suggestive of acute coronary syndrome (ACS) should be sent to the emergency department for further evaluation. (See "Electrocardiogram in the diagnosis of myocardial ischemia and infarction".)

ECG findings in patients with pericarditis may mimic anterior myocardial infarction and may vary as the disease progresses.

Findings of PR segment depression, ST segment elevation, and T-wave inversions are consistent with pericarditis. These findings are typically more diffuse than those found in patients with myocardial ischemia. (See "Acute pericarditis: Clinical presentation and diagnosis", section on 'Electrocardiogram'.)

Pericarditis is discussed below (see 'Nonischemic cardiac disease' below), and treatment is presented elsewhere. (See "Acute pericarditis: Treatment and prognosis".)

The most common ECG findings in patients with pulmonary embolism are tachycardia, and nonspecific ST segment and T wave changes. [17] (see "Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism", section on 'Electrocardiography'). The treatment of pulmonary embolism is discussed elsewhere. (See "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults".)

Patients without ECG findings of ischemia, pericarditis, or pulmonary embolism should be evaluated for other causes of chest pain.

Indications for chest radiograph — Chest radiograph should be obtained in patients with concern for pneumonia, pneumothorax, acute chest syndrome, heart failure, or rib fracture.

Evaluation for stable myocardial ischemia — After excluding life-threatening causes of chest pain, identifying patients with stable myocardial ischemia is the next priority. Evaluation is indicated in patients with classic symptoms but also in those without classic angina who have no other obvious etiology for their chest pain, or in those with multiple risk factors for cardiovascular disease (eg, diabetes, hyperlipidemia, hypertension and/or tobacco use). Features of chest pain that increase and decrease the likelihood of myocardial ischemia are presented in the table (table 6). Certain medical conditions may worsen ischemic symptoms (table 3).

Symptoms – 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, meals, sexual intercourse, or cold.

Ischemic chest pain often radiates (to the neck, throat, teeth, jaw, upper extremities, and shoulders), and may be associated with dyspnea, nausea and vomiting, diaphoresis, presyncope, or palpitations (from ventricular ectopy) [18]. Wide chest pain radiation increases the likelihood of myocardial infarction [19-21].

The onset of ischemic pain is often gradual (over a few minutes) with an increasing intensity over time. The pain generally does not last longer than 20 to 30 minutes, although it may be more prolonged in the setting of a myocardial infarction. (See "Approach to the patient with suspected angina pectoris", section on 'Symptoms'.)

Some patients (eg, women, older adults, or persons with diabetes) with myocardial ischemia may present without typical anginal symptoms. There is some evidence to suggest that patients with "nonspecific" chest pain may have an increased risk of mortality, particularly from coronary heart disease (CHD) [22-25]. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on 'Atypical presentations'.)

Risk assessment – Elements of patient history which increase the likelihood of myocardial ischemia include older age, family history of cardiovascular disease (table 7), tobacco or cocaine use, diabetes mellitus, hypertension, hyperlipidemia, and certain lifestyle factors.

Estimating the patient's 10-year risk of cardiovascular disease can help with baseline risk assessment. We typically use the 2013 Pooled Cohort Equations CV Risk Calculator from the American College of Cardiology/American Heart Association (calculator 2) for baseline risk assessment [26,27]. Other options include the Multi-Ethnic Study of Atherosclerosis (MESA) risk calculator, which can be used with or without a coronary artery calcium score (calculator 3), or the Framingham risk score, which has separate calculators for men (calculator 4) and women (calculator 5) [28]. (See "Atherosclerotic cardiovascular disease risk assessment for primary prevention in adults: Our approach" and "Overview of established risk factors for cardiovascular disease", section on 'Established risk factors for atherosclerotic CVD' and "Cardiovascular disease risk assessment for primary prevention: Risk calculators".)

Next steps – Clinical decision rules, such as the INTERCHEST score, can estimate the likelihood of coronary artery disease in primary care patients with chest pain and help to determine the need for additional cardiac work-up. We use the INTERCHEST score in outpatients whose initial evaluation does not suggest a clear cardiac etiology. It is most useful for differentiating individuals who are at low risk for unstable CAD from those who are at higher risk and require urgent evaluation [29,30]. .Based on risk factors and risk stratification, patients should undergo nonurgent or urgent additional evaluation with stress testing, coronary computed tomography angiography (CCTA), or coronary angiography. (See "Chronic coronary syndrome: Overview of care" and "Selecting the optimal cardiac stress test", section on 'Indications for stress testing'.)

Characteristics of other etiologies — If low suspicion exists for myocardial ischemia, further evaluation is directed by the most likely etiology based on the initial evaluation.

Nonischemic cardiac disease — Key diagnoses include pericarditis, heart failure, and aortic stenosis. (See 'Other cardiac causes' above.)

Elements of the history include elicitation of symptoms of pericarditis (sharp pleuritic chest pain), heart failure (dyspnea, peripheral edema, cough), aortic stenosis (exertional dyspnea, exertional angina, exertional presyncope or syncope), and mitral stenosis (exertional dyspnea, decreased exercise tolerance).

Patients in whom pericarditis is suspected should have the following examinations performed:

A cardiac examination while lying supine and while sitting up and leaning forward (picture 1). Classically, patients will have symptom relief with sitting up, and this is also the best position in which to evaluate the patient for a pericardial rub (movie 1) (see "Acute pericarditis: Clinical presentation and diagnosis", section on 'Pericardial friction rub' and "Acute pericarditis: Clinical presentation and diagnosis", section on 'Clinical features'). Diagnostic criteria of ECG indicative of acute pericarditis and myopericarditis are presented in the table (table 8).

Evaluation for pulsus paradoxus (an abnormally large decrease in systolic blood pressure [>10 mmHg] on inspiration), which is indicative of cardiac tamponade (see "Cardiac tamponade", section on 'Pulsus paradoxus'). If pulsus paradoxus if found or if the ECG demonstrates findings concerning for cardiac tamponade, the patient should be sent to the emergency department.

The approach to management of patients with pericarditis is discussed separately. (See "Acute pericarditis: Treatment and prognosis".)

Patients with symptoms and physical examination consistent with either aortic stenosis or mitral stenosis should have an echocardiogram for definitive diagnosis and to determine the severity of valvular disease. (See "Clinical manifestations and diagnosis of aortic stenosis in adults" and "Rheumatic mitral stenosis: Clinical manifestations and diagnosis".)

The approach to management of patients with heart failure is reviewed separately. (See "Overview of the management of heart failure with reduced ejection fraction in adults".)

Gastrointestinal disease — Evaluation for gastrointestinal disease involves elicitation of symptoms of heartburn, indigestion, regurgitation, and pain associated with food intake, all of which make a gastrointestinal etiology more likely. Common etiologies are discussed above. (See 'Gastrointestinal' above.)

There is considerable overlap between symptoms of gastrointestinal disease and myocardial ischemia. Discomfort that reliably occurs with eating, or that is reliably and repeatedly palliated by antacids or food is likely of gastroesophageal origin. However, relief of pain following the administration of a "gastrointestinal cocktail" (eg, viscous lidocaine and antacid) does not reliably distinguish gastrointestinal from ischemic chest pain [31]. Similarly, pain that responds to sublingual nitroglycerin is frequently thought to have a cardiac etiology but may also be due to esophageal origin [32].

Patients whose symptoms are consistent with angina should have an evaluation for myocardial ischemia prior to evaluation/treatment for gastrointestinal etiologies, particularly if they have risk factors for cardiovascular disease. (See 'Gastrointestinal' above and 'Evaluation for stable myocardial ischemia' above.)

Patients with a negative cardiac evaluation and anginal-like chest pain often have gastroesophageal reflux disease (GERD) [33-35]. GERD is associated with heartburn, regurgitation, cough, and dysphagia (table 9). GERD can be diagnosed based on these symptoms and response to therapy, with initial therapy depending on the severity of symptoms. (See "Medical management of gastroesophageal reflux disease in adults", section on 'Initial management' and "Evaluation of the adult with chest pain of esophageal origin" and "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)

Belching, a bad taste in the mouth, and difficult or painful swallowing are suggestive of esophageal disease (see "Pill esophagitis", section on 'Clinical manifestations' and "Evaluation of the adult with chest pain of esophageal origin"). Patients with dysphagia should be evaluated based on potential etiologies (table 10). (See "Approach to the evaluation of dysphagia in adults".)

Further evaluation of esophageal or peptic ulcer disease will likely involve consultation with a gastroenterologist for determination of the appropriate diagnostic procedure.

Pulmonary disease — Key symptoms in patients with pulmonary disease include pleuritic chest pain, dyspnea, and cough. Obtaining a history of chronic lung disease (eg, asthma, COPD, sarcoidosis), malignancy, prior pulmonary embolism, or systemic autoimmune disease can be helpful in the diagnosis. A chest radiograph is usually necessary. Potential etiologies include pulmonary embolism, pneumothorax, pleuritis, asthma or COPD exacerbation, or pneumonia. (See 'Pulmonary' above.)

Physical examination findings in patients with a small pneumothorax may be limited. However, characteristic physical findings when a large pneumothorax is present include decreased chest excursion, enlarged hemithorax, diminished breath sounds, absent tactile or vocal fremitus, hyperresonant percussion, and, rarely, subcutaneous emphysema. (See "Clinical presentation and diagnosis of pneumothorax", section on 'Clinical manifestations'.)

Musculoskeletal disease — Musculoskeletal etiologies are the most common causes of chest pain. Well-localized pain associated with point tenderness is more likely to be musculoskeletal in origin [36]. Body position or movement may exacerbate chest pain of musculoskeletal origin. Musculoskeletal complaints outside the chest are suggestive of a musculoskeletal etiology for chest pain. For example, pain in the neck, thoracic spine, or shoulder may cause referred pain to the chest. Chronic widespread musculoskeletal pain is associated with fibromyalgia. (See "Clinical evaluation of musculoskeletal chest pain".)

If the evaluation is consistent with musculoskeletal pain (eg, point tenderness that is reproducible with palpation) with no evidence of underlying systemic etiology, it is reasonable to defer diagnostic studies and prescribe a therapeutic trial of physical therapy or nonsteroidal antiinflammatory medication which may help confirm the diagnosis if there is improvement [37]. If there is concern for underlying systemic disease, then the appropriate evaluation should be initiated. (See 'Musculoskeletal' above and "Management of isolated musculoskeletal chest pain" and "Clinical evaluation of musculoskeletal chest pain", section on 'Diagnostic approach'.)

Psychiatric disease — The most common psychiatric diseases associated with chest pain are panic disorder and depression. Patients with depressed mood, decreased appetite, or sleep disturbances may have depression. Classic associated symptoms in patients with panic attack include fear and tachycardia. The following validated screening question is good for ruling out a diagnosis of panic attack/disorder when patients answer no: “In the past four weeks, have you had an anxiety attack (suddenly feeling fear or panic)?” [38]. A "no" answer to this question makes the diagnosis of panic attack/disorder very unlikely (negative likelihood ratio [LR] 0.09).

A "yes" answer moderately increases the likelihood of panic attack (positive likelihood ratio [LR] 4.2). These patients should undergo additional evaluation for other psychiatric disorders (eg, panic disorder, major depressive disorder, generalized anxiety disorder) and receive education about the likely etiology of their symptoms and initial management, which might include cognitive behavioral therapy and/or antidepressant medication. (See "Psychotherapy for panic disorder with or without agoraphobia in adults", section on 'Cognitive-behavioral therapy' and "Management of panic disorder with or without agoraphobia in adults".)

Other conditions — If other etiologies have been evaluated and ruled out or the history and physical examination are not consistent with those etiologies, we use a knowledge of dermatomes and spinal and visceral pain referral patterns to guide to the evaluation of other less common causes of chest pain (eg, zoster) and pain referred to the chest (eg, from the gallbladder, diaphragm, or from a disc herniation). Hyperesthesia, particularly when associated with a rash, is often due to herpes zoster. Patients with referred pain will often have associated symptoms or physical examination findings that support a particular diagnosis.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Chest pain (The Basics)")

Beyond the Basics topic (see "Patient education: Chest pain (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Common causes – The most common etiologies of chest pain in primary care practice include musculoskeletal and gastrointestinal conditions. (See 'Introduction' above and 'Differential Diagnosis' above.)

Initial triage and evaluation – The initial assessment should serve to identify patients with life-threatening conditions who need to be transferred to the emergency department (see 'Initial triage' above). Further evaluation (after excluding life-threatening causes) starts with a history and physical examination to assess the probability of specific causes of chest pain and determine the need for further testing. An ECG is warranted in many patients. (See 'Indications for electrocardiogram' above.)

Life-threatening conditions – Patients with unstable vital signs or concern for life-threatening etiology (eg, acute coronary syndrome [ACS], pulmonary embolism, aortic dissection, esophageal rupture, tension pneumothorax, cardiac arrhythmias, cardiac tamponade) should be referred to the emergency department. (See 'Life-threatening conditions' above and "Evaluation of the adult with chest pain in the emergency department".)

Suspected acute coronary syndrome – Concern for ACS may be based on symptoms (angina pectoris at rest, or prolonged or progressing episodes) or ECG changes. Patients with suspected ACS should have an ECG performed and be transferred immediately to an emergency department. If available, patients should also be given aspirin (162 to 325 mg) and appropriate initial interventions (eg, sublingual nitroglycerin). (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department".)

Evaluation of stable angina – Patients who have symptoms consistent with stable angina should be evaluated for myocardial ischemia. Evaluation for coronary heart disease (CHD) may also be warranted in patients with chest pain whose symptoms are not strongly suggestive of angina but do not have another obvious etiology for their chest pain. The INTERCHEST clinical prediction rule can be used to estimate the risk of CAD in specific patients and help guide next steps in management. (See 'Evaluation for stable myocardial ischemia' above.)

Evaluation of other causes – In patients with a negative workup for myocardial ischemia, or in whom suspicion is low, further evaluation is based upon the most likely etiologies that emerge from the initial evaluation. (See 'Characteristics of other etiologies' above.)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges James L Meisel, MD, FACP, Daniel Cottrell, MD, Michael Yelland, MD, and John R McConaghy, MD, CPE, FAAFP, who contributed to earlier versions of this topic review.

  1. Rui P, Okeyode T. National Ambulatory Medical Care Survey: 2016 national summary tables. Available at: https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf (Accessed on February 26, 2021).
  2. 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.
  3. 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.
  4. Heron M. Deaths: Leading Causes for 2017. Natl Vital Stat Rep 2019; 68:1.
  5. von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med 2000; 160:2977.
  6. Pate JW, Walker WA, Cole FH Jr, et al. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989; 47:689.
  7. Yada H, Soejima K. Management of Arrhythmias Associated with Cardiac Sarcoidosis. Korean Circ J 2019; 49:119.
  8. Huffman JC, Pollack MH, Stern TA. Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management. Prim Care Companion J Clin Psychiatry 2002; 4:54.
  9. Fleet RP, Dupuis G, Marchand A, et al. Panic disorder, chest pain and coronary artery disease: literature review. Can J Cardiol 1994; 10:827.
  10. 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.
  11. Evans DW, Lum LC. Hyperventilation: An important cause of pseudoangina. Lancet 1977; 1:155.
  12. 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.
  13. Ben Freedman S, Tennant CC. Panic disorder and coronary artery spasm. Med J Aust 1998; 168:376.
  14. 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.
  15. Talarico GP, Crosta ML, Giannico MB, et al. Cocaine and coronary artery diseases: a systematic review of the literature. J Cardiovasc Med (Hagerstown) 2017; 18:291.
  16. 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.
  17. Shopp JD, Stewart LK, Emmett TW, Kline JA. Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis. Acad Emerg Med 2015; 22:1127.
  18. 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.
  19. Davies HA, Jones DB, Rhodes J, Newcombe RG. Angina-like esophageal pain: differentiation from cardiac pain by history. J Clin Gastroenterol 1985; 7:477.
  20. Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. The rational clinical examination. Is this patient having a myocardial infarction? JAMA 1998; 280:1256.
  21. 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.
  22. 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.
  23. Ruigómez A, Rodríguez LA, Wallander MA, et al. Chest pain in general practice: incidence, comorbidity and mortality. Fam Pract 2006; 23:167.
  24. 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.
  25. 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.
  26. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:S49.
  27. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 139:e1082.
  28. 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.
  29. Sox HC, Aerts M, Haasenriter J. Applying a Clinical Decision Rule for CAD in Primary Care to Select a Diagnostic Test and Interpret the Results. Am Fam Physician 2019; 99:584.
  30. International Working Group on Chest Pain in Primary Care (INTERCHEST), Aerts M, Minalu G, et al. Pooled individual patient data from five countries were used to derive a clinical prediction rule for coronary artery disease in primary care. J Clin Epidemiol 2017; 81:120.
  31. 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.
  32. 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.
  33. 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.
  34. Borzecki AM, Pedrosa MC, Prashker MJ. Should noncardiac chest pain be treated empirically? A cost-effectiveness analysis. Arch Intern Med 2000; 160:844.
  35. 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.
  36. Verdon F, Burnand B, Herzig L, et al. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract 2007; 8:51.
  37. 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.
  38. Löwe B, Gräfe K, Zipfel S, et al. Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians' diagnosis. J Psychosom Res 2003; 55:515.
Topic 6832 Version 53.0

References

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