Evaluation and Management of Left-Sided Pleuritic Chest Pain
While pain worsening with deep inspiration markedly reduces the probability of acute coronary syndrome, you must still obtain an ECG within 10 minutes and measure cardiac troponin to exclude life-threatening causes before attributing symptoms to benign etiologies. 1
Initial Diagnostic Approach
Immediate Actions (Within 10 Minutes)
- Obtain a 12-lead ECG immediately to evaluate for STEMI, pericarditis, or other concerning findings, regardless of clinical setting 1
- Measure cardiac troponin as soon as possible after presentation if acute coronary syndrome is in the differential 1, 2
- Perform focused cardiovascular examination to identify life-threatening causes including pulmonary embolism, aortic dissection, pneumothorax, or pericarditis 1, 2
Key Clinical Features to Assess
Pain characteristics that guide diagnosis:
- Pleuritic pain (sharp, worse with breathing) suggests: pulmonary embolism, pericarditis, pneumonia, pneumothorax, or costochondritis rather than acute coronary syndrome 1, 3, 2
- Chest wall tenderness on palpation markedly reduces probability of ACS and suggests musculoskeletal causes like costochondritis 1
Life-Threatening Causes to Exclude
Pulmonary Embolism (Most Common Serious Cause)
- Present in 5-21% of patients with pleuritic chest pain presenting to emergency departments 4, 5
- Classic presentation: Tachycardia plus dyspnea in >90% of patients; pain with inspiration 1
- Use validated clinical decision rules to guide further testing with D-dimer, ventilation-perfusion scans, or CT angiography 2, 5
- Critical pitfall: PE can occur even when chest radiograph, ECG, and arterial blood gases are normal 2
Pericarditis
- Characteristic triad: Fever, pleuritic chest pain that worsens when supine and improves leaning forward, pericardial friction rub 1, 2
- Order inflammatory markers and consider echocardiography if pericarditis is suspected 2
- ECG shows diffuse ST-elevation (different pattern than STEMI) 1
Pneumothorax
- Presentation: Dyspnea and pain on inspiration with unilateral absence of breath sounds 1, 2
- Obtain chest radiography for diagnosis 2
Acute Coronary Syndrome
- Although pleuritic pain is atypical for ACS, do not exclude it based on pain characteristics alone 1, 2
- Women and elderly patients (≥75 years) are at particular risk for underdiagnosis when presenting with atypical symptoms 2
- Serial ECGs should be performed if initial ECG is nondiagnostic and clinical suspicion remains high 1
Common Benign Causes (After Excluding Life-Threatening Conditions)
Viral Pleurisy
- Most common cause of pleurisy after serious conditions are excluded 4, 5
- Common viral pathogens: Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, Epstein-Barr virus 5
- Treatment: NSAIDs for pain management 4, 5
Costochondritis
- Diagnosed by tenderness of costochondral joints on palpation 1, 3
- Treatment: NSAIDs and reassurance 6
Pneumonia
- Features: Fever, localized chest pain (may be pleuritic), friction rub, regional dullness to percussion, egophony 1, 3
- Obtain chest radiography and treat with appropriate antibiotics 3
Management Algorithm
If evaluated in office setting:
- Transport urgently to ED by EMS (not personal automobile) if clinical evidence suggests ACS or other life-threatening causes 1
- Do not delay transfer for troponin or other diagnostic testing in the office setting 1
If evaluated in emergency department:
- Complete evaluation with ECG, troponin, and chest radiography for all patients with pleuritic chest pain 1, 2, 4
- Consider CT pulmonary angiography for unexplained pleural effusion or when PE remains in differential despite negative initial workup 7
- Serial auscultation is important as pericardial or pleural rubs may be transient 8
Treatment based on final diagnosis: