![]() 2 Differentiating ischemic from nonischemic causes is often challenging because patients with ischemic chest pain may appear well. 2, 3, 5, 6 No definitive diagnosis may be found in as many as 15% of patients. 2 Other potential factors include pulmonary etiologies (pneumonia, pulmonary embolism ), psychological etiologies (panic disorder), and nonischemic cardiovascular disorders (congestive heart failure, thoracic aortic dissection). 2 – 4 The most common causes of chest pain in the primary care population are chest wall pain (20% to 50%), reflux esophagitis (10% to 20%), and costochondritis (13%). 1 Cardiac disease is the leading cause of death in the United States, yet only 2% to 4% of patients presenting to a primary care office with chest pain will have unstable angina or an acute myocardial infarction. Other less common, but important, diagnostic considerations include acute pericarditis, pneumonia, heart failure, pulmonary embolism, and acute thoracic aortic dissection.Īpproximately 1% of all ambulatory visits in primary care settings are for chest pain. In those with low suspicion for ACS, consider other diagnoses such as chest wall pain or costochondritis, gastroesophageal reflux disease, and panic disorder or anxiety states. Those at low or intermediate risk of ACS can undergo exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging. Patients with suspicion of ACS or changes on electrocardiography should be transported immediately to the emergency department. Twelve-lead electrocardiography is recommended to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions. The Marburg Heart Score and the INTERCHEST clinical decision rule can also help estimate ACS risk. A combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease as the cause of chest pain. Initial evaluation is based on determining whether the patient needs to be referred to a higher level of care to rule out acute coronary syndrome (ACS). Approximately 1% of primary care office visits are for chest pain, and 2% to 4% of these patients will have unstable angina or myocardial infarction. ![]()
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