Emergency Department Workup for Pleuritic Chest Pain
The appropriate ED workup for pleuritic chest pain must include an ECG within 10 minutes of arrival, cardiac troponin measurement, and chest radiography to evaluate for potentially life-threatening causes including pulmonary embolism, pericarditis, pneumothorax, and pneumonia. 1
Initial Assessment
- Obtain a focused history emphasizing characteristics of pain (sharp, stabbing pain that increases with inspiration), duration of symptoms, and associated features 1
- Perform a focused cardiovascular examination to aid in diagnosis of serious causes (e.g., pulmonary embolism, aortic dissection, pneumothorax) and identify complications 1
- Acquire and review an ECG within 10 minutes of arrival to evaluate for STEMI or other concerning findings 1, 2
- Measure cardiac troponin as soon as possible after presentation in all patients with acute chest pain and suspected ACS 1, 3
- Order chest radiography for all patients with pleuritic chest pain 4, 5
Differential Diagnosis Considerations
Pulmonary Embolism
- Most common serious cause of pleuritic chest pain (5-21% of ED presentations with pleuritic pain) 4, 6
- Typically presents with tachycardia and dyspnea in >90% of patients 1
- Use validated clinical decision rules to guide further testing (D-dimer, V/Q scan, CT angiography) 4, 7
- Consider PE even when chest radiograph, ECG, and arterial blood gases are normal 7, 8
Pericarditis
- Look for fever, pleuritic chest pain that worsens when supine, and pericardial friction rub 1, 3
- ECG may show widespread ST-elevation (typically concave upward) or PR depression 3
- Order inflammatory markers (CRP, ESR) and consider echocardiography 3
Pneumothorax
- Presents with dyspnea and pain on inspiration, unilateral absence of breath sounds 1
- Chest radiography is essential for diagnosis 4
Pneumonia
- Look for fever, localized chest pain, regional dullness to percussion, and egophony 1
- Chest radiography is diagnostic 4, 5
Other Considerations
- Myocarditis: fever, chest pain, heart failure, S3 1
- Aortic dissection: severe pain with abrupt onset, pulse differential, widened mediastinum on CXR 1
- Viral pleuritis: common cause after excluding serious conditions 4, 5
Special Population Considerations
- Women: Obtain history emphasizing accompanying symptoms more common in women with ACS; women are at risk for underdiagnosis 1
- Older patients (≥75 years): Consider ACS when accompanying symptoms such as shortness of breath, syncope, or acute delirium are present 1
- Diverse populations: Address language barriers with formal translation services 1
Common Pitfalls to Avoid
- Attributing pleuritic chest pain to benign causes without excluding serious conditions first 2, 4
- Relying on a single normal ECG to rule out serious conditions when clinical suspicion remains high 2
- "Thinking the best" rather than "thinking PE" in patients with pleuritic chest pain 7
- Misdiagnosing PE as viral pleuritis or pneumonia, leading to delayed diagnosis 8