What a Chest X-ray Can Show in Patients with Chest Pain
A chest radiograph is useful to evaluate for cardiac, pulmonary, and thoracic causes of chest pain, though it often cannot definitively diagnose the underlying etiology of chest pain. 1
Potential Findings on Chest X-ray in Chest Pain Evaluation
Cardiac Findings
- Chest X-ray can demonstrate cardiac enlargement (cardiomegaly), which may be associated with heart failure or myocardial infarction 1
- Pulmonary edema and signs of congestive heart failure may be visible, which can be associated with acute myocardial infarction 1
- While myocardial infarction itself is generally not directly diagnosable on chest X-ray, associated findings such as pulmonary congestion may be present 1
Vascular Findings
- Widened mediastinum may suggest aortic dissection, though chest X-ray is not sensitive enough to rule out this diagnosis 1
- Pulmonary artery enlargement may suggest pulmonary embolism, though further testing is required for confirmation 1
- Pleural effusions may be visible and can be associated with various cardiac and pulmonary conditions 1
Pulmonary Findings
- Pneumonia with associated infiltrates 1
- Pneumothorax, which can present with chest pain mimicking cardiac conditions 1
- Pulmonary masses or nodules that may cause chest pain 2
- Pleural disease including effusions or thickening 1
Musculoskeletal Findings
- Rib fractures, though chest X-ray has limited sensitivity (only detected in 4.9% of cases in one study) 1
- Bony lesions or metastases that may cause chest wall pain 1
- Chest X-ray is insensitive for detecting abnormalities of rib cartilages, costochondral junctions, and costovertebral joints 1
Limitations of Chest X-ray in Chest Pain Evaluation
- In one study of emergency department patients with nontraumatic chest pain, only 6.4% had findings on chest X-ray that were clinically relevant to emergency care 1
- Chest X-ray cannot establish or exclude chronic ischemic heart disease 1
- Chest X-ray is insensitive for detecting coronary artery calcification 1
- Chest X-ray has lower sensitivity for detecting conditions like pulmonary embolism compared to other imaging modalities 1, 3
- Portable bedside chest X-rays have particularly limited sensitivity for important causes of acute dyspnea such as pulmonary embolism, pneumothorax, and pulmonary edema 3
Clinical Utility and Recommendations
- Despite limitations, chest radiography is recommended by the American College of Cardiology/American Heart Association guidelines for the evaluation of acute chest pain 1
- The yield of chest radiography depends on pretest probability and will be higher when history or physical examination suggests specific diagnoses 1
- Chest X-ray should not delay urgent revascularization if indicated in patients with suspected acute coronary syndrome 1
- Application of appropriate use criteria could potentially reduce unnecessary chest X-rays by up to 47% without missing significant abnormalities in most cases 4
When Additional Imaging Is Needed
- Normal chest X-ray findings do not exclude serious pathology; further imaging with CT, MRI, or other modalities may be necessary when clinical suspicion remains high 5, 6
- For suspected coronary artery disease, additional testing such as coronary CT angiography, stress testing, or conventional angiography is typically required 1
- When chest pain persists despite normal chest X-ray findings, further evaluation with advanced imaging modalities should be considered 2, 6