What is the appropriate evaluation and treatment for a patient with pleuritic chest pain?

Evaluation and Management of Pleuritic Chest Pain

For a patient presenting with pleuritic chest pain, immediately obtain an ECG within 10 minutes, chest X-ray, and cardiac troponin to exclude life-threatening causes—particularly pulmonary embolism, acute coronary syndrome, pneumothorax, aortic dissection, and pericarditis—before considering benign etiologies. 1

Initial Diagnostic Approach

Immediate Testing (All Patients)

• ECG within 10 minutes to identify STEMI, pericarditis patterns (widespread ST-elevation with PR depression), or signs of pulmonary embolism 1
• Chest radiography to evaluate for pneumothorax (unilateral absence of breath sounds with hyperresonance), pneumonia (regional dullness, egophony), pleural effusion, or widened mediastinum suggesting aortic dissection 1
• Cardiac troponin measurement as soon as possible to exclude myocardial injury, recognizing that 13% of patients with pleuritic pain may have acute coronary syndrome 1, 2

Critical Physical Examination Findings

• Vital signs: Tachycardia and tachypnea are present in >90% of pulmonary embolism cases 1
• Pleural friction rub: A biphasic, creaking leather-like sound heard during both inspiration and expiration indicates pleural inflammation 1, 2
• Unilateral decreased breath sounds with hyperresonance suggests pneumothorax; with dullness suggests large pleural effusion 1
• Pericardial friction rub with pain that improves sitting forward and worsens supine suggests pericarditis 1

Life-Threatening Causes to Exclude First

Pulmonary Embolism (Most Common Serious Cause)

• Present in 5-21% of ED patients with pleuritic pain 3, 4
• Clinical presentation: Dyspnea followed by pleuritic chest pain, tachycardia, tachypnea 1
• Risk stratification: Use validated clinical decision rules to determine pretest probability 5
• D-dimer testing: Using age- and sex-specific cutoffs may be useful in low-to-intermediate pretest probability patients; negative D-dimers allow discharge without further testing, while positive values require CTA 5
• Definitive imaging: CTA with PE protocol is recommended for stable patients with high clinical suspicion 5
• Pleural effusion develops in 46% of PE cases and is frequently hemorrhagic 2, 6

Pneumothorax

• Classic triad: Dyspnea, pleuritic pain on inspiration, unilateral absence of breath sounds with hyperresonant percussion 1
• Chest X-ray confirms diagnosis 7
• Treatment: Tube thoracostomy in fourth/fifth intercostal space midaxillary line for significant pneumothorax; needle decompression at second intercostal space midclavicular line for tension pneumothorax with hemodynamic compromise 7

Acute Coronary Syndrome

• May present with pleuritic pain in 13% of patients 1, 2
• Critical pitfall: 7% of patients with reproducible chest wall tenderness on palpation still have ACS—never assume musculoskeletal origin excludes cardiac disease 1, 2
• Sharp, pleuritic pain makes ischemic heart disease less likely but does not rule it out 1
• Nitroglycerin response should NOT be used diagnostically, as relief does not confirm or exclude myocardial ischemia 1

Aortic Dissection

• Sudden onset "ripping" chest pain radiating to the back 1
• Pulse differential present in 30% of cases 1
• Widened mediastinum on chest X-ray warrants immediate CTA 1

Pericarditis

• Sharp, pleuritic pain that improves sitting forward and worsens supine 5, 1
• ECG hallmark: Widespread ST-elevation with PR depression (may be transient) 5
• Pericardial friction rub may be audible 5
• TTE is effective to determine presence of pericardial effusion, ventricular wall motion abnormalities, or restrictive physiology 5
• CMR with gadolinium is useful if diagnostic uncertainty exists or to determine extent of pericardial inflammation and fibrosis 5

Common Non-Life-Threatening Causes

Pneumonia

• Localized pleuritic pain, fever, productive cough 1
• Regional dullness to percussion, egophony, possible friction rub 1
• Chest X-ray shows infiltrate 1
• Follow-up: Document radiographic resolution with repeat chest X-ray six weeks after treatment in patients with persistent symptoms, smokers, and those >50 years 4

Viral Pleurisy

• Most common benign cause after exclusion of serious conditions 3, 4
• Common viral pathogens: Coxsackieviruses, RSV, influenza, parainfluenza, mumps, adenovirus, CMV, EBV 4
• Diagnosis of exclusion after ruling out life-threatening causes 3
• Treatment: NSAIDs for pain management 3, 4

Musculoskeletal (Costochondritis/Tietze Syndrome)

• Tenderness of costochondral joints on palpation 1
• Critical caveat: 7% of patients with reproducible chest wall pain still have ACS—palpable tenderness does NOT exclude serious pathology 1

Myopericarditis Evaluation

When myocardial injury is present with nonobstructive coronary arteries:

• CMR with gadolinium contrast is recommended to distinguish myopericarditis from other causes including MINOCA 5
• CMR is useful to determine presence and extent of myocardial and pericardial inflammation and fibrosis 5
• Myocarditis typically presents with chest pain, fatigue, exercise intolerance, and heart failure signs (S3 gallop) distinguishing it from isolated pericarditis 5, 1
• Troponin is usually elevated in myocarditis; minimally elevated troponin in pericarditis does not confer worse prognosis 5

Critical Pitfalls to Avoid

• Never assume reproducible chest wall tenderness excludes serious pathology: 7% have ACS 1
• Never use nitroglycerin response diagnostically: Relief does not confirm or exclude ischemia 1
• Never delay transfer for troponin testing in office settings: Transport suspected ACS patients urgently to ED by EMS 1
• Never assume sharp, pleuritic pain excludes cardiac ischemia: It makes ischemia less likely but does not rule it out 1
• Always consider PE in undiagnosed exudative pleural effusions: PE is the most commonly overlooked disorder in patients with pleural effusion 6, 8

Treatment Principles

• Pain management: NSAIDs for viral pleurisy and nonspecific pleuritic pain 3, 4
• Specific treatment targeted at underlying cause once identified 3
• Anticoagulation: Bloody pleural fluid from PE is NOT a contraindication to anticoagulant therapy 6
• Pleural effusion from PE: No specific treatment required beyond treating the PE itself 6