A Synopsis of AFP's Outpatient Diagnosis of Acute Chest Pain in Adults" by McConaghy and Oza

This is a quuick review of:

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

Am Fam Physician. 2013 Feb 1;87(3):177-182.

     According to this article, 1% of  outpatient office visits is for chest pain, and 1.5% of these patients will have angina or an MI.  The other will have diagnosis such as chest wall pain (20%), reflux (13%) and costrochondritis (13%). One of the most important jobs of a physician is to tweeze out the serious problems with the non urgent ones.
     The first thing you want to do is to determine of the pain is coronary ischemia(ACS) and to decide if the patient need to be referred for troponins, a stress test, or an angiogram. Important characteristics that should worry you are, if the patient is a male, over 60 years old, is diaphoretic, if the chest pain is pleuritic, sharp, stabbing, not reproducible by palpation, worse with exercise,radiating down one or both arms, a third heart sound, or a past medical history of angina/ known vascular disease. If a patient had several of these, then you should consider referring this patient. Patients may also use words like "discomfort, tightness, squeezing, or indigestion" instead of "pain".
     Patients who are over 40 and have comorbidities should also be considered.
     Any patient with chest pain should get an ECG. Typical red flags on ECG are ST changes, new onset left bundle branch blocks, Q waves, and T wave inversions.
     If you do not think the patient is having a life threatening condition, it is important to know the common signs and symptoms of the other diseases in the differential of chest pain.

Chest Wall Pain- localized pain, stinging pain, reproducible by palpation, and an absense of cough.
GERD- burning retrosternal pain, acid regurgitation, and a sour, bitter taste in the mouth.
Costochondritis- pain reproducible by palpation to the costochondral joints.
Panic/ Anxiety- can be determined through specialized questionnaires, or a past history of panic attacks
Pericarditis- pleuritic chest pain, friction rub, ST-T changes, PR depression, Pin worse with inspiration and better with leaning forward.

     Other less common diseases in the differential are  pneumonia, heart failure, PE (see well criteria) or aortic dissection.