From the Guidelines
Investigations for pleuritic chest pain should begin with a thorough history and physical examination, followed by a chest X-ray as the initial imaging study, and for patients older than 50 years, an age-adjusted D-dimer threshold should be used to determine whether imaging is warranted, as recommended by the American College of Physicians 1. When evaluating patients with pleuritic chest pain, it is crucial to consider the potential for pulmonary embolism (PE), especially in patients with high pretest probability, where imaging with CT pulmonary angiography (CTPA) is recommended 1.
- Key initial tests include:
- Chest X-ray
- Electrocardiogram (ECG)
- Complete blood count
- Basic metabolic panel
- Cardiac enzymes (troponin)
- D-dimer, using age-adjusted thresholds for patients over 50 years old
- If the chest X-ray is inconclusive, a chest CT scan with contrast should be considered to evaluate for pulmonary embolism, pneumonia, or pleural disease.
- For suspected cardiac causes, an echocardiogram may be necessary to assess for pericarditis or other cardiac abnormalities.
- Arterial blood gases can help evaluate oxygenation status and acid-base balance.
- Specific inflammatory markers like C-reactive protein and erythrocyte sedimentation rate may be useful when inflammatory conditions are suspected.
- In cases where pleural effusion is present, thoracentesis with fluid analysis should be performed to determine if the fluid is exudative or transudative, as guided by the clinical context and patient risk factors 1. The selection and urgency of these investigations should be guided by the pattern of pain, associated symptoms, and risk factors, with the goal of promptly identifying life-threatening conditions while minimizing unnecessary testing and radiation exposure, particularly in patients with a history of multiple CT scans for PE 1.
From the Research
Pleuritic Chest Pain Investigations
Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling 2. The investigations for pleuritic chest pain include:
- Clinical evaluation to determine if the pain is related to breathing, which is characteristic of pleuritic chest diseases 3
- History and physical examination to rule out serious causes such as pulmonary embolism, myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax 2
- Electrocardiography and troponin assays to rule out myocardial infarction 2
- Chest radiography to rule out pneumonia and pneumothorax 2
- Validated clinical decision rules, such as the use of d-dimer assays, ventilation-perfusion scans, or computed tomography angiography, to guide the diagnosis of pulmonary embolism 2, 4
- Pulmonary angiography, which is considered the gold standard for diagnosing pulmonary embolism 4
Diagnostic Considerations
The diagnosis of pleuritic chest pain requires a high degree of clinical acumen and a high degree of suspicion for pulmonary embolism 5. The presence of risk factors, such as a history of deep vein thrombosis or pulmonary embolism, should be considered when evaluating a patient with pleuritic chest pain 5. A normal chest radiograph, ECG, and arterial blood gases do not rule out pulmonary embolism, and further investigation is necessary to confirm or exclude the diagnosis 5.
Management
The management of pleuritic chest pain depends on the underlying diagnosis 2. Nonsteroidal anti-inflammatory drugs are appropriate for pain management in those with virally triggered or nonspecific pleuritic chest pain 2. In patients with persistent symptoms, persons who smoke, and those older than 50 years with pneumonia, it is important to document radiographic resolution with repeat chest radiography six weeks after initial treatment 2.