Pericarditis should be considered in patients with the clinical triad of pleuritic chest pain that increases with inspiration or when reclining pericardial friction rub and diffuse electrocardiographic ST-T wave changes.Īt least two of the following findings: localized muscle tension stinging pain pain reproducible by palpation absence of coughīurning retrosternal pain, acid regurgitation, sour or bitter taste in the mouth one-week trial of high-dose proton pump inhibitor relieves symptoms Physicians should consider using a validated brief questionnaire to confirm diagnosis. Panic disorder and anxiety state often cause chest pain and shortness of breath. Gastroesophageal reflux disease should be considered in patients with burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth. ![]() ![]() Patients with localized musculoskeletal pain that is reproducible by palpation, or pain reproducible by palpation in the parasternal/costochondral joints, likely have chest wall pain or costochondritis. The presence of ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversion increase the likelihood of acute coronary syndrome or acute myocardial infarction, and the patient should be referred to a higher level of care (emergency department or hospital). Twelve-lead electrocardiography should be performed in persons at high risk of myocardial ischemia who present with chest pain. Physicians should consider applying a validated clinical decision rule to predict heart disease as a cause of chest pain. Persons with a higher likelihood of acute coronary syndrome should be referred to the emergency department or hospital.Ĭlinical characteristics traditionally associated with an increased likelihood of acute myocardial infarction include male sex plus age older than 60 years diaphoresis pain that radiates to the shoulder, neck, arm, or jaw and a history of angina or acute myocardial infarction. 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). 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. ![]() 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. ![]() The physician should consider patient characteristics and risk factors to help determine initial risk. 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. 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.
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