Evaluation of chest pain in the ambulatory setting

1. Evaluation of Chest Pain in
the Ambulatory Setting
Kerolus Shehata, MD

2. Educational Objectives
 Identify various etiologies of chest pain (CP) and
their prevalence.
 Determine which patients with chest pain should be
referred for emergent care .
 Review indications and absolute contraindications
for cardiac stress testing.
 Learn the likelihood ratios for a MI based on
different patient descriptions of chest pain.

3. Prevalence & Goals
 Patients often do not use the term pain to describe
their symptoms, but frequently use other terms
like discomfort, tightness, squeezing, or indigestion
 1% of PCP visits are for chest pain, and 1.5% of these
patients will have ACS.
 Initial goal: R/O ACS & other life threatening
conditions.
 Persons with a higher likelihood of ACS should be
referred to the ED.

4. Case 1

5. Case 1 Questions
1. What are the various etiologies of chest pain,
organized by organ system?
2. Which are most common in the outpatient setting?
3. What work-up would be appropriate for Mr. CP?
4. Which patients presenting with chest pain should
we urgently send to the ED?

6. Causes of CP in the Outpatient Setting
Chest wall pain: 20%
GERD: 13%
Costochondritis: 13%

7. Life threatening causes of CP
 ACS (STEMI and its equivalents, NSTEMI, UA)
 Pericardial tamponade
 Severe myocarditis
 Aortic dissection
 PE
 Pneumothorax
 Esophageal rupture (Boerhaave's syndrome)

8. Typical vs Atypical Anginal CP
N.B: ALWAYS use your clinical judgement

9. Likelihood Ratio
• Used for assessing a value of performing a diagnostic test or exam finding.
• Uses the sensitivity and specificity of the test to determine whether a test
result usually changes the probability that a disease state exists.
• Sensitivity and specificity determine how good the test is.
• LR predicts the risk of disease for a particular test result.

10. Chest pain rule in/rule out characteristics

11. Validated clinical decision rule for
identifying patients with CP caused by ACS
Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease in primary care:
development and validation of a simple prediction rule. CMAJ. 2010;182(12):1295–1300.

12. Risk assessment, Cont’d

13. Risk stratification and Role of EKG
 12 lead EKG is the test of choice in the initial
evaluation of patients with chest pain.
 ST segment changes (elevation or depression),
new-onset left bundle branch block, presence of Q
waves, and new onset T wave inversion increase
the likelihood of ACS.
 Patient’s likelihood has to be determined based
on the clinical impression (history, physical
examination, risk factors, and 12-lead ECG)

14. Chest wall pain
1. localized muscle tension
2. Stinging pain.
3. Pain that is reproducible by palpation
4. Absence of a cough.
Bösner S, Becker A, Hani MA, et al. Chest wall syndrome in primary care patients
with chest pain: presentation, associated features and diagnosis.
Fam Pract. 2010;27(4):363-369.
 Having at least 2/4 findings has 77% positive predictive
value for chest wall pain.
 Having 0-1/4 findings has 82% negative predictive value.

15. Costochondiritis vs Tietze syndrome
Costochondritis (Chondrodynia) Tietze syndrome
More common Less common
Usually in patients >40 years old Usually in patients <40 years old
Affects costochondral (2nd to 5th) or
chondrosternal joints
Primarily affects the costochondral
joints (2nd and 3rd)
Affects >1 joint in 90% of cases Affects only 1 joint in 70% of cases
Not associated with local swelling Associated with local swelling
Normal inflammatory markers High ESR and CRP

16. GERD
 Burning retrosternal pain
 Sour or bitter taste in the mouth
 May cause chronic cough and asthma-like symptoms
No useful physical examination maneuvers exist to
assist in establishing the diagnosis.
one-week trial of a high-dose PPI is modestly
sensitive and specific for GERD, with modest LRs
(LR+ = 3.1; LR– = 0.3)

17. Panic disorder & anxiety state
 One in four persons with a panic attack will have
chest pain and shortness of breath.
 Panic may cause chest pain and vice versa.
Löwe B, Gräfe K, Zipfel S, et al. Detecting panic disorder in medical and
psychosomatic outpatients: comparative validation of the Hospital Anxiety and
Depression Scale, the Patient Health Questionnaire, a screening question, and
physicians’ diagnosis. J Psychosom Res. 2003; 55(6):515-519.
One question (In the past 4 weeks, have you had
an anxiety attack [suddenly feeling fear or
panic]?) is sensitive (93%) and modestly specific
(78%) in detecting panic disorder.

18. Pericarditis
 Triad of pleuritic chest pain, pericardial friction rub,
and diffuse electrocardiographic ST-T wave changes.
 New onset CP that increases with inspiration or
when reclining, and is lessened by leaning forward.

19. Pneumonia
 Common symptoms include fever, chills, productive
cough, and pleuritic chest pain.
 Clinical impression is modestly useful for ruling in or
out pneumonia (LR+ = 2.0; LR– = 0.24).
 The test of choice for diagnosing pneumonia is CXR.

20. Heart Failure
 Most patients with heart failure present with
dyspnea on exertion, although some will have CP.
 A history of heart failure or acute MI best predicts
the presence of heart failure (LR+ = 5.8 and 3.1,
respectively).
 Clinical impression/judgment is predictive of heart
failure (LR+ = 9.9; LR– = 0.65).
 Pulmonary edema on CXR is highly predictive of
CHF (LR+ = 11.0).

21. Pulmonary Embolism
 Dyspnea, tachycardia, and/or chest pain are present
in 97 % of those diagnosed with PE.
 There is no single clinical feature that effectively
rules it in or out.

22. PE diagnostic algorithm

23. Acute Thoracic Aortic Dissection
 History and physical examination are only modestly
useful for ruling in or out the condition; CP or back
pain and a pulse differential in the upper extremities
modestly increase the likelihood Dx (LR+ = 5.3).

24. Case 1, Cont’d

25. Case 1 Questions, Cont’d
1. Does Mr. CP need a cardiac stress test and why?
2. Does your pretest probability of his level of cardiac
disease influence whether you should order a stress
test?
3. Who should not be referred for a stress test?

26. Diamond and Forrester model
• White boxes:
PTP <15%. No further
testing.
• Blue boxes:
PTP 15-65%. May need
Exercise EKG or non-
invasive imaging.
• Orange boxes:
PTP 66-85%. Should
have a non-invasive
imaging.
• Red boxes:
PTP>85%. Assume
CAD is present.

27. Duke Clinical Score

28. Which stress test to order?

29. Whom not to stress?
Any unstable patient: active chest pain, high risk unstable angina, symptomatic severe
AS, uncontrolled arrhythmia, decompensated heart failure, acute pulmonary embolus
and acute aortic dissection

30. Case 1, Cont’d

31. References
 Brown J. Evaluation of Chest Pain. BMJ Best Practice. 2018.
 McConaghy JR and Oza RS. Outpatient diagnosis of acute chest pain in adults.
American Family Physician. 2013: 87(4):177-82.
 Bösner S, Becker A, Haasenritter J, et al. Chest pain in primary care:
epidemiology and pre-work-up probabilities. Eur J Gen Pract. 2009;
15:141.
 D'Agostino RB Sr, Vasan RS, Pencina MJ, et al. General cardiovascular risk
profile for use in primary care: the Framingham Heart Study. Circulation.
2008; 117:743.
 Swap CJ, Nagurney JT. Value and limitations of chest pain history in the
evaluation of patients with suspected acute coronary syndromes. JAMA.
2005; 294:2623.
 Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease
in primary care: development and validation of a simple prediction rule.
CMAJ. 2010;182(12):1295–1300.

32. Thank You