Evaluation and Management of Left-Sided Chest Pain with Deep Breathing
Sharp chest pain that worsens with deep breathing is unlikely to be ischemic heart disease and typically suggests pleuritic causes such as pericarditis, pulmonary embolism, pneumonia, or pneumothorax—but cardiac causes must still be excluded with objective testing before assuming a benign diagnosis. 1
Immediate Assessment Required
Obtain a 12-lead ECG within 10 minutes of presentation, regardless of clinical setting. 1 Even when pleuritic pain characteristics suggest a non-cardiac cause, an ECG is mandatory to exclude life-threatening conditions. 1
Critical Life-Threatening Differentials to Exclude First
- Pulmonary embolism: Presents with pleuritic pain, dyspnea, and tachycardia in >90% of cases 1, 2. This is the most common serious cause of pleuritic chest pain, found in 5-21% of emergency department presentations. 2
- Acute pericarditis: Characterized by sharp pleuritic pain that worsens with inspiration and lying supine, often with fever and friction rub 1. ECG shows diffuse ST-elevation with PR depression. 3
- Pneumothorax: Presents with dyspnea and pain on inspiration, with unilateral absence of breath sounds 1, 3
- Pneumonia: Features localized pleuritic pain with friction rub, fever, regional dullness to percussion, and egophony 1, 4
- Acute coronary syndrome: While less likely with pleuritic features, ACS can present with atypical pleuritic pain in 13% of cases 3. Never assume sharp pain excludes cardiac disease. 3
Focused Physical Examination
Perform a cardiovascular and pulmonary examination looking for specific findings: 1
- Vital signs: Assess for tachycardia, tachypnea, fever, hypotension, and oxygen saturation 1, 4
- Respiratory system: Listen for decreased breath sounds (pneumothorax), friction rub (pericarditis, pneumonia), crackles (pneumonia), and assess for respiratory distress 1, 4
- Cardiovascular system: Auscultate for pericardial friction rub, new murmurs, S3 gallop 1
- Chest wall: Palpate for reproducible tenderness, but remember that 7% of patients with palpable tenderness still have ACS 3
Diagnostic Algorithm Based on Clinical Presentation
If High-Risk Features Present (Transport to ED Immediately):
- Prolonged ongoing pain, associated dyspnea, diaphoresis, syncope, or hemodynamic instability 5
- Transport by EMS, not personal vehicle 3
- Measure cardiac troponin as soon as possible after ED arrival 1, 3
If Pleuritic Features Predominate:
Obtain chest radiograph to evaluate for pneumonia, pneumothorax, or pleural effusion 1, 3, 6
Apply validated clinical decision rules for pulmonary embolism (such as Wells criteria or PERC rule) to guide D-dimer testing and CT angiography 2, 6
Serial ECGs if Initial ECG Nondiagnostic:
If clinical suspicion remains high and symptoms persist, repeat ECGs to detect evolving ischemic changes 1. Consider supplemental leads V7-V9 if posterior MI suspected. 3
Management Based on Diagnosis
- Pericarditis: NSAIDs for pain management 2. Document resolution of symptoms and ECG changes.
- Viral pleurisy: NSAIDs appropriate for pain control 2
- Pneumonia: Appropriate antibiotics with follow-up chest radiograph at 6 weeks in patients >50 years, smokers, or those with persistent symptoms 2
- Pulmonary embolism: Anticoagulation per protocol 2
- Musculoskeletal (costochondritis): Characterized by tenderness of costochondral joints 1, 4, treated with NSAIDs
Critical Pitfalls to Avoid
- Never assume pleuritic pain excludes ACS—13% of ACS cases present with pleuritic features 3
- Never rely on reproducible chest wall tenderness alone—7% with palpable tenderness have ACS 3
- Never use nitroglycerin response as diagnostic—esophageal spasm and other conditions also respond 5, 3
- Never delay ED transfer for troponin testing in office settings when ACS suspected 1, 3