Outpatient diagnosis of acute chest pain in adults.pdf

February 1, 2013 ◆ Volume 87, Number 3 /afp American Family Physician 177 Outpatient Diagnosis of Acute Chest Pain in Adults JOHN R. McCONAGHY, MD, CPE, and RUPAL S. OZA, MD, MPH, The Ohio State University, Columbus, Ohio pproximately 1 percent of all ambu- latory visits in the primary care setting are for chest pain.1 Car- diac disease is the leading cause of death in the United States, yet only 1.5 percent of patients presenting to a pri- mary care office with chest pain will have unstable angina or an acute myocardial infarction (MI).2 The most common causes of chest pain in the primary care population include chest wall pain (20 percent); reflux esophagitis (13 percent); and costochondri- tis (13 percent),2 although in practice, cos- tochondritis is often included in the chest wall pain category. Other considerations include pulmonary (e.g., pneumonia, pul- monary embolism), gastrointestinal (e.g., gastroesophageal reflux disease [GERD]), and psychological (e.g., anxiety, panic disor- der) etiologies, and cardiovascular disorders (e.g., acute congestive heart failure, acute thoracic aortic dissection). Table 1 lists the differential diagnosis of chest pain.3-15 Initial Evaluation Algorithmic approaches to the diagnosis and workup of the patient presenting with chest pain in the office setting have not been spe- cifically studied. Differentiating ischemic from nonischemic causes often is difficult, and patients with chest pain with an isch- emic etiology often appear well. As such, the initial diagnostic approach should always consider a cardiac etiology for the chest pain, unless other causes are apparent.16 The first decision point for most physi- cians is whether or not the chest pain is caused by coronary ischemia.16 Acute coro- nary syndrome (ACS) is a constellation of clinical findings that suggests acute myocar- dial ischemia encompassing unstable angina and acute MI. Angina has been described as deep, poorly localized chest or