Approximately 1 percent of
primary care office visits are for
chest pain, and 1.5 percent of these
patients will have
unstable angina or acute
myocardial infarction. The initial
goal in
patients presenting with
chest pain is to determine if the
patient needs to be referred for further testing to rule in or out
acute coronary syndrome and
myocardial infarction. The
physician should consider
patient characteristics and
risk factors to help determine initial
risk. Twelve-
lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset
left bundle branch block, presence of Q waves, and new-onset T
wave inversions. For
persons in whom the suspicion for
ischemia is lower, other
diagnoses to consider include
chest wall pain/costochondritis (localized
pain reproducible by
palpation),
gastroesophageal reflux disease (burning retrosternal
pain,
acid regurgitation, and a sour or bitter
taste in the
mouth), and
panic disorder/
anxiety state. Other less common but important diagnostic considerations include
pneumonia (
fever, egophony, and dullness to
percussion),
heart failure,
pulmonary embolism (consider using the Wells criteria), acute
pericarditis, and acute
thoracic aortic dissection (acute
chest or
back pain with a
pulse differential in the
upper extremities).
Persons with a higher likelihood of
acute coronary syndrome should be referred to the
emergency department or
hospital.