From the Guidelines
When evaluating chest pain in a young adult male, a systematic approach beginning with a thorough history and physical examination is crucial to identify potential life-threatening causes, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. The initial assessment should focus on ruling out life-threatening causes such as acute coronary syndrome, pulmonary embolism, aortic dissection, and pneumothorax.
- Key components of the history include:
- Nature of the chest pain
- Onset and duration
- Location and radiation
- Precipitating factors
- Relieving factors
- Associated symptoms
- The physical examination should include vital signs, cardiac and pulmonary examination, and assessment for signs of trauma or infection. The diagnostic workup should start with an ECG, complete blood count, basic metabolic panel, cardiac enzymes (troponin), and a chest X-ray, as recommended by the guideline 1.
- If cardiac etiology is suspected, high-sensitivity troponin measurements at 0 and 3 hours can help confirm the diagnosis.
- For suspected pulmonary embolism, D-dimer testing and CT pulmonary angiography if D-dimer is elevated can guide management decisions. Risk stratification tools like the HEART score for cardiac causes or Wells criteria for pulmonary embolism can help guide management decisions, as they have been shown to be effective in identifying patients at low risk for adverse outcomes 1. In young males, non-cardiac causes are more common, including:
- Musculoskeletal pain
- Gastroesophageal reflux
- Anxiety
- Costochondritis Treatment should target the underlying cause, such as:
- NSAIDs for musculoskeletal pain (ibuprofen 400-600mg every 6 hours)
- Proton pump inhibitors for GERD (omeprazole 20mg daily)
- Appropriate cardiac medications if indicated This approach balances the need to identify serious conditions while recognizing that most chest pain in young adults has benign causes, avoiding unnecessary testing and radiation exposure while ensuring potentially life-threatening conditions are not missed, as emphasized in the guideline 1.
From the Research
Differential Diagnosis of Chest Pain in a Young Adult Male
The differential diagnosis of chest pain in a young adult male can be complex and varied. Some possible causes of chest pain include:
- Cardiac conditions such as acute coronary syndrome, myopericarditis, or pulmonary embolism 2, 3
- Inflammatory or infectious conditions of the myocardium and pericardium 2
- Other non-cardiac conditions such as musculoskeletal or gastrointestinal issues
Diagnostic Considerations
When evaluating a young adult male with chest pain, it is essential to consider the patient's medical history, risk factors, and physical examination findings. Diagnostic tests such as electrocardiogram (ECG), troponin levels, and echocardiography can help identify potential causes of chest pain 2, 3.
- A normal or nonspecific ECG and negative cardiac biomarkers may suggest a low risk of acute coronary syndromes (ACS) 4, 5, 6
- The presence of elevated troponin levels and chest pain may raise suspicion of an acute ischemic event, but alternative diagnoses such as myopericarditis should also be considered 2
- Echocardiography can be a useful tool in differentiating between ACS and pulmonary embolism, and can also help identify other cardiac conditions such as myopericarditis 3
Risk Stratification
Young adult males with chest pain can be stratified into different risk categories based on their medical history, risk factors, and diagnostic test results.