Chest Pain: Tools to Improve Your In-office Evaluation

Your patient, Amy Z., age 58, was given a diagnosis of hypertension 10 years ago and since then has been maintained on hydrochlorothiazide 50 mg/d and lisinopril 10 mg/d. In the office today, she reports intermittent chest tightness and heaviness. She has no history of coronary artery disease (CAD), cerebrovascular disease, or peripheral vascular disease. She attributes her chest discomfort to emotional stress. She recently started a job after having been unemployed but still has no health insurance and is concerned about losing her house.

She denies orthopnea and resting or exertional dyspnea and says she never gets chest pain while climbing stairs. Her blood pressure is elevated at 180/110 mm Hg, but her other vital signs are normal (pulse, 70 beats/min; respiratory rate, 18 breaths/min). On physical examination, she has no venous distension in her neck and her lungs are clear. A cardiac exam reveals a regular rate and rhythm, with a normally split S1 and S2 and no murmurs, rubs, or gallops. Palpation of the chest does not reproduce her chest pain.

You are concerned that your patient’s chest pain could be from heart disease, but she wants to defer additional testing because of the cost, stating, “It’s all due to my stress.”

HOW WOULD YOU PROCEED?
Whether they go to the emergency department (ED) or to their primary care provider’s office, most patients who seek treatment for chest pain don’t have life-threatening cardiac illness. Of the 8 million patients who visit an ED for chest pain each year, only 13% are diagnosed with acute coronary syndrome (ACS).^1,2 Among those seen for chest pain in a primary care office, only a minority (approximately 1.5%) have unstable heart disease.^3-5 Cross-sectional studies indicate that musculoskeletal chest wall pain (or “chest wall syndrome [CWS]”) is the most common cause of chest pain in patients who seek treatment in the office, followed by gastrointestinal (GI) disease, stable heart disease, psychosocial or psychiatric conditions, pulmonary disease, and other cardiovascular conditions (see Table 1).^3,6,7

When evaluating patients with chest pain in the office, the challenge is to appropriately evaluate and manage those who are at low risk for ACS, while at the same time identifying and arranging prompt transfer or referral for the minority of patients who are at high cardiac risk. This article describes how to determine which patients require emergency treatment, which tools to use to screen for ACS and other potential causes of chest pain, and how to proceed when initial evaluation and testing do not point to a diagnosis.

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