Chest pain

Approximately 8 million patients seen at emergency rooms each year for chest pain.

Approximately 11,000 patients presenting with chest pain are inadvertently discharged from the emergency department with acute myocardial infarction resulting in more than 25% of malpractice awards.

Affects 20-40% general population during their lifetime.

It is the reason for approximately 1% of primary care visits.

The percentage of patients with ACS discharged inappropriately to home during initial emergency department visit is low, approximately 2.2%.

As few as 5-10% of patients presenting with chest pain will ultimately be diagnosed with acute coronary syndrome, a diagnosis encompassing ST segment elevation myocardial infarction, non-STEMI and unstable angina.

CP accounts for approximately 10% of all emergency department visits, and up to 90% have no underlying cardiovascular disease.

Patients with symptoms suggestive of acute myocardial infarction account for about 10% of all ED consultations, with only 15-20% of them diagnosed with acute myocardial infarction.

Most patients presenting to an emergency department for chest pain have a non-cardiac etiology.

Most community patients with chest pain in a normal resting EKG do not require further cardiac evaluation.

Stable ischemia occurs in 11% of patients presenting with chest pain in the primary care setting and less than 4% or experiencing acute coronary syndrome.

Approximately 2.1% of patients with AMI and 2.3% of patients with unstable angina are mistakenly discharged from emergency departments.

Patients with AMI inappropriately sent home from an emergency department have approximately a two fold higher risk adjusted thirty-day mortality then for those patients hospitalized (Pope JH et al).

25% of population experiences some form of chest pain in their lifetime.

More than 3 million patients admitted through the emergency room/year.

30-40% of the more than 8 million patients who present each year to the emergency departments have acute coronary artery syndromes.

Differential diagnosis includes pulmonary, musculoskeletal, gastrointestinal, cardiovascular, dermatologic and psychiatric illnesses.

Differential diagnosis includes: myocardial infarction, unstable angina,aortic dissection, myocarditis, pericarditis, hypertrophic cardiomyopathy, stress cardiomyopathy, cervical disc disease, costochondritis, herpes zoster, neuropathic pain, rib fracture, pneumonia, pulmonary embolus, tension pneumothorax, pleurisy, cholecystitis, peptic ulcer disease, gastrointestinal reflux disease, esophageal spasm, Boerhave syndrome, pancreatitis, depression, anxiety disorder, panic disorder, and somatization and psychogenic pain disorder.

Chest pain differential diagnosis:




Acute Coronary Syndromes









Unstable angina



Aortic dissection



Cardiac tamponade



Pulmonary embolism



Tension pneumothorax



Esophageal perforation (Boerhhaave’s syndrome)



Coronary artery dissection
























Cocaine-associated chest pain



Myocardial rupture






Stable angina



Asthma exacerbation



Valvular Heart Disease



Aortic Stenosis



Mitral valve prolapse



Hypertrophic cardiomyopathy















Esophageal Spasm



Gastroesophageal Reflux Disease (GERD)



Peptic Ulcer Disease



Biliary Colic



Muscle sprain



Rib Fracture









Spinal Root Compression



Thoracic outlet syndrome



Herpes Zoster / Postherpetic Neuralgia



Psychologic / Somatic Chest Pain






Panic attack

May arise from any organ of the chest including: the heart, lungs, blood vessels, the esophagus and the chest wall.

Individuals who develop cardiac chest pain are generally treated empirically as an acute coronary syndrome, and are immediately tested for elevations in their blood levels of enzymes such as creatine kinase isoenzymes or troponin that are markers for cardiac damage.

The use of high sensitivity cardiac troponin is the preferred biomarker for ruling out acute myocardial infarction in patients with chest pain.

Studies have demonstrated that the negative predictive value of us-cTn can be improved to 99.1 to 100% by integrating serial measurements.

They are also tested by ECG which may suggest variant angina if it shows elevations in the ST segment or an elevated ST segment plus a widening of the R wave during symptoms that are triggered by a provocative agent with ergonovine or acetylcholine.

The electrocardiogram may show depressions rather than elevations in ST segments but in all diagnosable cases clinical symptoms should be promptly relieved and ECC changes should be promptly reversed by rapidly acting sublingual or intravenous nitroglycerin.

However, the gold standard for diagnosing variant angina is to visualize coronary arteries by angiography before and after injection of a provocative agent such as ergonovine, methylergonovine or acetylcholine to precipitate an attack of vasospasm.

A positive test to these inducing agents is defined as a 90%, although some experts require lesser, (70%) constriction of involved arteries.

Typically, these constrictions are fully reversed by rapidly acting nitroglycerin.

Standard test for excluding the diagnosis of coronary artery disease is coronary angiography.

More than half of the patients who present to the emergency department with chest pain suggestive of acute coronary ischemia have no cardiac problems.

Nonspecific CP is pain not explainable by a pathophysiologic process.

Angina pain results from chronic narrowing of epicardial coronary arteries due to atherosclerosis.

Other types of chest pain due to ischemic mechanism as above, that is, decreased blood flow to the epicardial coronary arteries can occur with myocardial infarction, vasospasm, aortic valve stenosis, coronary artery embolism, aortic dissection with extension into coronary osmium, primary coronary artery dissection.

Chest pain caused by ischemia at the level of the microvasculature, that is, the endocardium, as opposed to the epicardium, include: Hypertension tachycardia, dilated cardiomyopathy, syndrome X, Tako-tsubo cardiomyopathy and inflammatory disease of the coronary arteries.

Approximately one third to one half of cases evaluated for chest pain with coronary arteriograms have normal studies.

Sources of non-cardiac chest pain include: musculoskeletal conditions, comprising approximately 25-50% of cases, gastrointestinal causes in 10-20% of cases, respiratory symptoms with respiratory upper and lower tract infections, asthma and COPD, count for approximately 12% of cases.

Psychological conditions such as anxiety, and panic disorders with chest pain, make up an additional 10% of non-cardiac chest pains.

Approximately 14-30% undergoing angiography for chest pain have no coronary artery disease or other processes such as coronary spasm, cardiomyopathy, or hypertrophy and the majority of these patients are women.

Persistent chest pain with non obstructed coronary arteries may be related to microvascular coronary dysfunction, which is related to an adverse prognosis, with increased cardiovascular events.

Abnormal heart nociception can cause persistent chest pain and is associated with adverse cardiac events.

Guidelines for the assessment of chest pain suggest that if the initial ECG is not diagnostic, but there is suspicion for acute coronary syndrome, serial ECGs at 15-30 minute intervals should be done to detect the development of ST-segment elevation or depression.

If there is a high suspicion for a STEMI in the setting of a nondiagnostic initial ECG, serial ECGs at 5-10 minute intervals or continuous 12 lead ST segment monitoring are recommended.

Atypical chest symptoms such as stabbing, pleuritic and pinprick pains are usually associated with non cardiac pain.

Chest x-rays are typically the first test in evaluating chest pain and can exclude pneumothorax, pneumonia, pleural effusion, and pulmonary edema, but lacks specificity and sensitivity for many other processes.

Symptoms of nausea and vomiting in association with chest pain increases the risk of acute coronary syndrome.

Chest symptoms relieved by rest or use of sublingual nitroglycerin are not predictive of cardiac disease.

Atypical chest pains associated with coronary artery disease more likely in the elderly, and women.

In a German study of 807 patients with nonspecific chest pain, 55.5% of patients had persistent pain and 10.7% had inappropriate healthcare evaluations (Glombiewski JA).

In patients in the emergency department with symptoms suggestive of acute coronary syndromes incorporating coronary CT angiography into triage strategy improved efficiency of clinical decision-making but resulted in increased downstream testing and radiation exposure with no decrease in overall cost of care (Hoffmann U et al).

In the above study the triage was associated with the shorter length of stay in the hospital and more direct discharges from the emergency department.

In an evaluation of 1000 consecutive patients presenting to the ED with nontraumatic chest pain, negative EKG, a single negative cardiac serum biomarker test: stress test results were positive for ischemia in 13%, negative in 64%, and nondiagnostic in 23%: At 30 days among patients with negative results only 1 (0.1%) had a non-Q waves MI compared with 0% among those whose study results were nondiagnostic and four ( 3.2%) among those with positive stress test results (Amsterdam EA et al ).

In the above study revascularization occurred in 0%, 3%, and 9.6% of patients, respectively: Suggesting positive and ambiguous test results predicted most cardiac events and procedures.

In a prospective study of patients for possible acute coronary syndromes involving 4181 patients presenting to an emergency department: All patients had no ischemic electrocardiography tests or a positive biomarker: provocative cardiac testing was positive for coronary ischemia in 11.2% and coronary obstructive disease was confirmed in 51.2% of these patients-a chest pain unit in an emergency department indicated that routine provocative cardiac testing generated a small therapeutic yield, new diagnoses of coronary arteries disease were uncommon, and false positives were (Hermann LK et al).

In adults with chest pain admitted to the hospital with two negative findings for serial biomarkers, non-concerning vital signs, and nonischemic electrocardiographic findings, short-term adverse cardiac events are rare, commonly iatrogenic, suggesting routine inpatient admission may not be beneficial for this group of patients (Weinstock MB et al).

In the low-to-intermediate risk patients with suspected acute coronary syndrome, an

undetectable hi sensitive troponin T value admission allows a safe discharge without

occurrence of death myocardial infarction within 90 days (Vafaie M et al).

After introduction of the hs-troponin test in emergency departments there is a decrease in the overall invasive and noninvasive diagnostic testing for chest pain.
Non-cardiac chest pain causes include: musculoskeletal conditions, comprising approximately 25-50% of cases, Gastrointestinal causes in 10-20% of cases, respiratory symptoms such as upper and lower respiratory tract infections, asthma, and COPD account for approximately 12% of cases.
Psychological conditions, such as anxiety and panic disorders and associated chest pain make up an additional 10% of cases.

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