From the Guidelines
The diagnostic approach to pleuritic chest pain should begin with a thorough history and physical examination, followed by initial evaluation with vital signs, oxygen saturation, and assessment for signs of respiratory distress, and then proceed with laboratory tests and imaging studies as indicated by the clinical presentation, with the most recent guidelines suggesting a CT pulmonary angiogram for suspected pulmonary embolism 1.
Initial Evaluation
The initial evaluation of a patient with pleuritic chest pain should include:
- Vital signs
- Oxygen saturation
- Assessment for signs of respiratory distress
- Laboratory tests, such as:
- Complete blood count
- Basic metabolic panel
- Cardiac enzymes (troponin)
- D-dimer
- Inflammatory markers like C-reactive protein and erythrocyte sedimentation rate
Imaging Studies
Imaging studies are essential in the diagnosis of pleuritic chest pain, and should include:
- Chest X-ray to evaluate for pneumonia, pneumothorax, or pleural effusion
- CT pulmonary angiogram if pulmonary embolism is suspected, particularly with an elevated D-dimer 1
- Electrocardiogram and echocardiogram for patients with concerning cardiac symptoms to assess for pericarditis or myocardial ischemia
- Thoracic ultrasound to evaluate for pleural effusion or chest CT to identify lung parenchymal disease, pleural thickening, or other thoracic pathologies if the diagnosis remains unclear after initial testing
Clinical Presentation
The urgency and extent of workup depend on the clinical presentation, with immediate attention required for patients showing signs of:
- Hemodynamic instability
- Respiratory compromise
- Other concerning features suggesting a life-threatening condition As noted in the guidelines, clinical signs, symptoms, and routine laboratory tests do not allow the exclusion or confirmation of acute PE but increase the index of its suspicion 1.
Recent Guidelines
The most recent guidelines suggest that evaluating the likelihood of PE in an individual patient according to the clinical presentation is of utmost importance in the interpretation of diagnostic test results and selection of an appropriate diagnostic strategy 1. The guidelines also emphasize the importance of knowledge of which predisposing factors for VTE are present in the evaluation of the likelihood of PE, which increases with the number of predisposing factors present 1.
From the Research
Diagnostic Approach to Pleuritic Chest Pain
The diagnostic approach to pleuritic chest pain involves a combination of clinical evaluation, laboratory tests, and imaging studies.
- The first step is to characterize the pain as pleuritic, which is sharp, stabbing, or burning pain in the chest that worsens with inhalation and exhalation 2.
- A validated clinical decision rule for pulmonary embolism should be employed to guide the use of additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography 2.
- Other serious causes of pleuritic chest pain, such as myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax, should be ruled out using history and physical examination, electrocardiography, troponin assays, and chest radiography 2.
- Validated clinical decision rules are available to help exclude coronary artery disease 2.
- Laboratory tests, such as d-dimer assays, can be used to rule out pulmonary embolism, but the Simplify D-dimer is not sufficiently sensitive to exclude the diagnosis of pulmonary embolism in all patients presenting with pleuritic chest pain 3.
- Respiratory dead space measurement is not a reliable diagnostic test for pulmonary embolism in outpatients with pleuritic chest pain 4.
- Imaging studies, such as chest radiography, ventilation-perfusion scans, and computed tomography angiography, can be used to diagnose pulmonary embolism, pneumonia, and pneumothorax 2, 4.
- In some cases, pleuritic chest pain can be caused by Antiphospholipid syndrome (APS), which can be diagnosed with abnormal blood clotting tests 5.
Differential Diagnosis
The differential diagnosis of pleuritic chest pain is broad and includes:
- Pulmonary embolism 2, 3, 4
- Myocardial infarction 2
- Pericarditis 2
- Aortic dissection 2
- Pneumonia 2, 6
- Pneumothorax 2, 6
- Viral infections, such as coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus 2
- Antiphospholipid syndrome (APS) 5