From the Guidelines
A comprehensive chest pain questionnaire is essential for guiding appropriate triage decisions and determining the need for urgent cardiac workup or less urgent evaluation for non-cardiac causes. When evaluating a patient with chest pain, it is crucial to consider the patient's clinical presentation, medical history, and risk factors for cardiac disease 1. The questionnaire should include questions about the pain's character, onset, location, radiation, severity, timing, exacerbating/alleviating factors, and associated symptoms. Ask about the quality of pain (sharp, dull, pressure, burning), when it started, exact location and radiation patterns, severity on a scale of 1-10, duration and frequency, what makes it better or worse, and accompanying symptoms like shortness of breath, nausea, or diaphoresis.
Include questions about cardiac risk factors such as family history, smoking, hypertension, diabetes, high cholesterol, and previous cardiac events. Document current medications, allergies, and recent activities before pain onset. Ask about previous similar episodes and their outcomes. This structured approach helps differentiate between cardiac causes (typically pressure-like, radiating to arm/jaw, associated with exertion) and non-cardiac causes (often sharp, positional, localized). According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline, an ECG should be performed for patients seen in the office setting with stable chest pain, and patients with clinical evidence of ACS or other life-threatening causes of acute chest pain should be transported urgently to the ED 1.
The use of risk scores such as the HEART score can aid in risk stratification and clinical management in both low-risk and intermediate-risk patients 1. Noninvasive imaging may be indicated for risk stratification and clinical management, but patient selection is critical to avoid unnecessary diagnostic imaging 1. The goal of the chest pain questionnaire is to quickly and accurately identify patients at high risk for cardiac events and initiate prompt treatment, while also avoiding unnecessary testing and reducing morbidity, mortality, and improving quality of life.
From the Research
Chest Pain Workup Questionnaire
The following points outline the key considerations for a chest pain workup:
- Initial Assessment: The history, physical examination, cardiac risk factors, electrocardiogram findings, and clinician judgment are crucial in evaluating chest pain 2.
- Laboratory Tests: New cardiac troponin assays can help rapidly exclude acute myocardial infarction, and serial troponin assays are pivotal in assessing patients with suspected acute coronary syndrome 2, 3.
- Imaging Modalities: Non-invasive cardiac imaging modalities, such as chest radiography, single photon-emission CT myocardial perfusion imaging, echocardiography, multidetector CT, PET, and MRI, can be used to evaluate patients with chest pain 4, 3.
- Risk Stratification: Risk stratification scores, such as the TIMI and GRACE scores, can be used to assess patients with known acute coronary syndrome, but may have limitations in undifferentiated chest pain patients 3.
- Coronary Computed Tomography Angiography: This imaging modality has demonstrated utility in evaluating patients presenting with acute chest pain, and can be used for further risk stratification 4, 3.
- Management: Aspirin and dual antiplatelet therapy are recommended for patients with suspected acute coronary syndrome, unless contraindicated, and other medical therapies, such as statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and oxygen, may also be used 5.
- Revascularization: Percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible for patients with ST-segment elevation myocardial infarction, and coronary artery bypass grafting may be considered for patients who require reestablishment of coronary artery flow 5.