What are the American Family Physician's recommendations for evaluating chest pain?

American College of Cardiology/American Heart Association Recommendations for Evaluation of Chest Pain

The evaluation of chest pain requires a focused history, physical examination, and appropriate diagnostic testing to identify potentially life-threatening causes, with an ECG obtained within 10 minutes of presentation for all patients with acute chest pain. 1

Initial Assessment and History Taking

Key Components of History

• Characteristics of pain: Obtain detailed information about:
  • Nature (pressure, heaviness, tightness vs. sharp, stabbing)
  • Onset and duration
  • Location and radiation
  • Severity
  • Precipitating factors (exertion, emotional stress)
  • Relieving factors
  • Associated symptoms 1

Pain Descriptors and Ischemia Risk

• Higher probability of ischemia: Central, pressure, heaviness, tightness, exertional/stress-related, retrosternal, squeezing, dull
• Lower probability of ischemia: Stabbing, fleeting, sharp, pleuritic, positional, reproducible by palpation 1

Special Considerations for High-Risk Populations

Women

• Women with chest pain are at risk for underdiagnosis
• Always consider potential cardiac causes in women
• Obtain history emphasizing accompanying symptoms more common in women with ACS 1

Older Patients (≥75 years)

• Consider ACS when accompanying symptoms include:
  • Shortness of breath
  • Syncope
  • Acute delirium
  • Unexplained falls 1

Diverse Patient Populations

• Use cultural competency and formal translation services when needed 1

Physical Examination

A focused cardiovascular examination should be performed to aid in diagnosis of ACS or other serious causes of chest pain and identify complications 1.

Key Physical Findings by Condition

• ACS: Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, MR murmur
• Pulmonary Embolism: Tachycardia, dyspnea, pain with inspiration
• Aortic Dissection: Pulse differential, connective tissue disorder signs
• Pneumonia: Fever, regional dullness to percussion, egophony
• Pneumothorax: Unilateral decreased/absent breath sounds
• Pericarditis: Friction rub, fever, pain increased in supine position 1

Diagnostic Testing

Electrocardiogram (ECG)

• All patients with acute chest pain: Obtain ECG within 10 minutes of arrival
• Office setting with stable chest pain: Perform ECG unless noncardiac cause is evident
• If ECG unavailable in office: Refer to ED for ECG 1

Cardiac Biomarkers

• ED presentation with suspected ACS: Measure cardiac troponin (cTn) as soon as possible
• Office setting: Avoid delayed transfer to ED for cTn testing 1

Setting-Specific Recommendations

Office/Outpatient Setting

• For stable chest pain: Perform ECG if available
• For suspected ACS or life-threatening causes: Transport urgently to ED via EMS
• Avoid: Delayed transfer to ED for cardiac troponin or other diagnostic testing 1

Emergency Department

• Obtain ECG within 10 minutes
• Measure cardiac troponin promptly
• Consider structured risk assessment protocols 1

Common Pitfalls to Avoid

1. Terminology pitfall: Do not describe chest pain as "atypical" - instead, categorize as cardiac, possibly cardiac, or noncardiac 1

2. Diagnostic pitfall: Do not use relief with nitroglycerin as a diagnostic criterion for myocardial ischemia 1

3. Women and elderly patients: Avoid underdiagnosis by maintaining high suspicion even with less typical presentations 1

4. Office setting: Do not delay transfer to ED when ACS is suspected 1

5. Relying solely on chest pain history: The chest pain history alone is not sufficient to rule out ACS without appropriate diagnostic testing 2

By following these evidence-based recommendations from the American College of Cardiology/American Heart Association, clinicians can effectively evaluate chest pain and reduce morbidity and mortality from potentially life-threatening conditions.