In an adult presenting to primary care with chest pain, what history elements, review of systems, physical exam components, and laboratory investigations are required, and what are the common etiologies?

Primary Care Evaluation of Chest Pain

Immediate Life-Threatening Conditions to Exclude First

Your first priority is to rapidly identify six conditions that can kill within minutes to hours: acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, esophageal rupture, and pericardial tamponade. 1, 2

• Obtain a 12-lead ECG within 10 minutes of presentation to detect ST-elevation myocardial infarction or other acute ischemic changes 1, 2
• Measure cardiac troponin immediately when ACS is suspected, as it is the most sensitive and specific biomarker for myocardial injury 1, 2
• Assess vital signs including heart rate, blood pressure in both arms, respiratory rate, and oxygen saturation to detect hemodynamic instability or pulse differentials 2

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Essential History Elements

Pain Characteristics That Increase ACS Likelihood

Document the exact quality, location, radiation pattern, onset, duration, and temporal relationship of the pain. 1, 2

• High-probability features for ischemia: Retrosternal pressure, squeezing, gripping, heaviness, tightness, or constriction that builds gradually over several minutes (not instantaneously) 1, 2
• Radiation pattern: Pain radiating to left arm, neck, jaw, or between shoulder blades suggests cardiac origin 1
• Duration: Anginal symptoms typically last several minutes; fleeting pain of only seconds is unlikely ischemic 1
• Precipitating factors: Physical exertion or emotional stress commonly trigger anginal symptoms 1
• Relieving factors: Rest typically improves stable angina, but do NOT use nitroglycerin response as a diagnostic criterion because esophageal spasm and other noncardiac conditions also respond 2, 3

Pain Characteristics Suggesting Alternative Diagnoses

• Sharp, stabbing pain worsening with inspiration and lying supine suggests pericarditis rather than ischemia, though this does NOT exclude ACS entirely—13% of patients with pleuritic features still had acute myocardial ischemia 1, 3
• Sudden-onset "ripping" or "tearing" pain radiating to the back is suspicious for aortic dissection, especially in hypertensive patients or those with known bicuspid aortic valve 1, 3
• Pain localized to a very small area or radiating below the umbilicus is unlikely myocardial ischemia 1
• Pain reproducible with chest wall palpation suggests costochondritis, which accounts for 43% of chest pain in primary care when cardiac causes are excluded 1, 3

Critical Associated Symptoms

Ask specifically about these symptoms, as they significantly increase ACS probability: 1, 2

• Dyspnea or shortness of breath 1, 2
• Diaphoresis 1, 2
• Nausea or vomiting 1, 2
• Lightheadedness, presyncope, or syncope 1, 2
• Palpitations 2

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Review of Systems (ROS)

Cardiovascular

• Prior history of coronary artery disease, myocardial infarction, or revascularization 2
• Known valvular heart disease or cardiomyopathy 3
• Palpitations or irregular heartbeat 2

Pulmonary

• Sudden dyspnea with pleuritic pain suggests pulmonary embolism, especially with risk factors (recent surgery, immobilization, malignancy, oral contraceptives) 1, 3
• Cough, fever, or sputum production suggests pneumonia 4

Gastrointestinal

• Burning retrosternal pain related to meals and relieved by antacids suggests gastroesophageal reflux disease 3
• History of forceful vomiting preceding chest pain raises concern for esophageal rupture (Boerhaave syndrome) 2

Musculoskeletal

• Pain affected by palpation, breathing, turning, twisting, or bending suggests chest wall origin 1, 3

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Cardiovascular Risk Factor Assessment

Document all traditional risk factors, as they inform pre-test probability: 1, 2

• Age and sex (men ≥45 years, women ≥55 years have higher risk) 2
• Diabetes mellitus 1, 2
• Hypertension 1, 2
• Hyperlipidemia 1, 2
• Current smoking 1, 2
• Family history of premature coronary artery disease (first-degree male relative <55 years or female relative <65 years) 1, 2

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Physical Examination Components

Vital Signs and General Appearance

• Hemodynamic instability: Systolic blood pressure <100 mmHg, heart rate >100 bpm or <50 bpm indicates high risk 2
• Blood pressure in both arms: Differential >20 mmHg suggests aortic dissection 2
• Respiratory rate and oxygen saturation: Tachypnea and hypoxemia suggest pulmonary embolism or pneumothorax 2
• Diaphoresis, pallor, or distress increases likelihood of serious pathology 1, 2

Cardiovascular Examination

• Jugular venous pressure: Elevated JVP suggests heart failure or pericardial tamponade 2
• Carotid pulse character: Slow-rising (tardus-parvus) pulse suggests aortic stenosis; rapid upstroke suggests aortic regurgitation 2
• Pulse differential between extremities: Present in ~30% of aortic dissections, more common in type A 2
• Heart sounds: S3 gallop indicates heart failure; new murmurs (mitral regurgitation suggests papillary muscle dysfunction; aortic regurgitation suggests dissection) 1, 2
• Pericardial friction rub: Pathognomonic for pericarditis 2, 3

Pulmonary Examination

• Unilateral absence of breath sounds indicates pneumothorax or massive pleural effusion 2
• Crackles suggest pulmonary edema from heart failure 1, 2
• Tracheal deviation with hypotension indicates tension pneumothorax 2

Chest Wall Examination

• Tenderness of costochondral joints reproducible with palpation confirms costochondritis 1, 3
• Subcutaneous emphysema points toward esophageal rupture or pneumomediastinum 2

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Laboratory Investigations

Mandatory Initial Tests

• High-sensitivity cardiac troponin: Measure immediately upon presentation; repeat at 1–3 hours (or 3–6 hours if conventional troponin) to improve diagnostic accuracy 1, 2
• 12-lead ECG: Obtain within 10 minutes; repeat serially if initial ECG is nondiagnostic but clinical suspicion remains high 1, 2

Additional Tests Based on Clinical Suspicion

• D-dimer: Useful to exclude pulmonary embolism and aortic dissection when levels <500 ng/mL 3
• Complete blood count: Evaluate for anemia or infection 5
• Basic metabolic panel: Assess renal function and electrolytes 5
• Chest X-ray: Evaluate for pneumothorax, pneumonia, pleural effusion, widened mediastinum (aortic dissection), or heart failure 2, 4

Troponin Interpretation

• A single high-sensitivity troponin below the limit of detection in patients with symptom onset ≥3 hours before arrival and a normal ECG is sufficient to exclude myocardial injury 2
• Up to 5% of ACS patients present with a normal initial ECG, so troponin testing is essential even when the ECG is normal 3
• Repeat troponin at 6–12 hours after initial presentation for definitive risk stratification, as initial troponin may be negative in early ACS 6

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Common Etiologies of Chest Pain

Life-Threatening Causes (Must Exclude First)

1. Acute Coronary Syndrome (20% in primary care, 45–60% in emergency settings): Retrosternal pressure building over minutes, radiation to left arm/jaw/neck, associated with diaphoresis, dyspnea, nausea 1, 3

2. Aortic Dissection: Sudden "ripping" or "tearing" pain radiating to back, pulse/BP differentials, new aortic regurgitation murmur 1, 3

3. Pulmonary Embolism: Sudden dyspnea with pleuritic pain, tachycardia (>90% of patients), tachypnea, risk factors present 1, 3

4. Tension Pneumothorax: Dyspnea, inspiratory chest pain, unilateral absent breath sounds, tracheal deviation, hypotension 2

5. Esophageal Rupture: History of forceful vomiting, subcutaneous emphysema, pneumothorax in ~20% 2

6. Pericardial Tamponade: Pleuritic pain worsening supine, hemodynamic compromise, elevated JVP 2

Serious But Non-Immediately Fatal Causes

1. Pericarditis: Sharp pleuritic pain worsening supine, improving when leaning forward, friction rub, fever 3

2. Myocarditis: Chest pain, fever, signs of heart failure, S3 gallop 3

3. Valvular Disease: Aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy 3

Common Benign Causes (43% in primary care)

1. Costochondritis/Tietze Syndrome: Tenderness of costochondral joints on palpation, pain reproducible with chest wall pressure 1, 3

2. Chest Wall Pain: Localized to small area, affected by palpation, breathing, turning, twisting, or bending 1, 3

3. Gastroesophageal Reflux Disease: Burning retrosternal pain related to meals, relieved by antacids 3

4. Psychiatric Causes (11% in primary care, 8% in emergency settings): Anxiety, depression, panic disorder 3

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Special Population Considerations

Women

Women are at high risk for underdiagnosis and more commonly present with accompanying symptoms rather than classic chest pain. 1, 2

• Emphasize accompanying symptoms: nausea, fatigue, dyspnea, jaw pain, neck pain, back pain, epigastric discomfort 1, 2
• Women more frequently describe pain as "tearing" and less often "grinding" 2

Older Adults (≥75 Years)

Consider ACS when accompanying symptoms include dyspnea, syncope, acute delirium, or unexplained falls—even without classic chest pain. 2, 3

Patients with Diabetes

• More likely to present with atypical symptoms including vague abdominal symptoms, confusion, or isolated dyspnea 2
• Higher risk for silent ischemia 2

Young Patients (<40 Years)

• Do NOT assume young age excludes ACS—it can occur even in adolescents without traditional risk factors 6
• Young patients without known cardiac history, no classic risk factors, and normal ECG have ACS risk of approximately 1.0–1.8% 6

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Critical Pitfalls to Avoid

1. Never use the term "atypical chest pain"—instead describe as cardiac, possibly cardiac, or noncardiac to prevent misinterpretation as benign 1, 2

2. Never rely on nitroglycerin response as a diagnostic criterion—esophageal spasm and other noncardiac conditions also respond 2, 3, 6

3. Never delay transfer to the emergency department for troponin testing in office settings—if ACS is suspected, immediate transport by EMS is required 2, 6

4. Never dismiss chest pain in women or elderly patients—they frequently present with atypical symptoms 2, 3

5. Never assume a normal initial ECG excludes ACS—30–40% of acute myocardial infarctions present with normal or nondiagnostic ECG 2

6. Never assume sharp, pleuritic pain excludes ACS—13% of patients with pleuritic features had acute myocardial ischemia 3

7. Physical examination contributes almost nothing to diagnosing myocardial infarction unless shock is present—do not be falsely reassured by a benign exam 2, 7

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Disposition Algorithm

High-Risk Features Requiring Immediate ED Transfer by EMS

Transport urgently by EMS (not personal automobile) if ANY of the following are present: 2, 6

• ST-elevation or new ischemic changes on ECG 2, 6
• Hemodynamic instability (SBP <100, HR >100 or <50) 2, 6
• Prolonged ongoing rest pain 2
• Associated diaphoresis, dyspnea, nausea, or syncope 2
• Age >75 years with accompanying symptoms 2, 3
• Elevated troponin above 99th percentile 2

Low-Risk Patients

• Normal ECG, negative troponin at presentation and 6–12 hours, no high-risk features: proceed to observation or stress testing before discharge 2