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The diagnostic work-up of chest pain depend on the cause and as well as their hemodynamic status.The first decision point for most physicians is to determine that chest pain is caused by coronary ischemia or not. There is no single diagnostic study of choice for the diagnosis of chest pain caused by [[Acute coronary syndromes|acute coronary syndrome]], however [[ECG]] and [[cardiac enzymes]] are the ''most'' important initial tes''t. [https://www.wikidoc.org/index.php/The_electrocardiogram ECG],[https://www.wikidoc.org/index.php/Transthoracic_echocardiography Transthoracic echocardiography],[https://www.wikidoc.org/index.php/Chest_X-rays Chest X-ray]'' is recommended in all [https://www.wikidoc.org/index.php/Patients patients] with suspected [https://www.wikidoc.org/index.php/Acute_pericarditis acute pericarditis]. [[Chest X-ray]] is the gold standard test for the diagnosis of [[pneumothorax]] or [[pneumonia]]. | The diagnostic work-up of chest pain depend on the cause and as well as their hemodynamic status.The first decision point for most physicians is to determine that chest pain is caused by coronary ischemia or not. There is no single diagnostic study of choice for the diagnosis of chest pain caused by [[Acute coronary syndromes|acute coronary syndrome]], however [[ECG]] and [[cardiac enzymes]] are the ''most'' important initial tes''t. [https://www.wikidoc.org/index.php/The_electrocardiogram ECG],[https://www.wikidoc.org/index.php/Transthoracic_echocardiography Transthoracic echocardiography],[https://www.wikidoc.org/index.php/Chest_X-rays Chest X-ray]'' is recommended in all [https://www.wikidoc.org/index.php/Patients patients] with suspected [https://www.wikidoc.org/index.php/Acute_pericarditis acute pericarditis]. [[Chest X-ray]] is the gold standard test for the diagnosis of [[pneumothorax]] or [[pneumonia]]. | ||
==Diagnostic Study of Choice== | ==Diagnostic Study of Choice== | ||
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{{Family tree| | | | | | | | | | A01 | | | |A01= [[Chest pain]] }} | |||
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{{Family tree| | | | | | | | | | A02 | | | |A02= [[History]], [[physical exam]] }} | |||
{{Family tree| | | | | | | | | | |!| | | | }} | |||
{{familytree | | | | | | | | | | A03 | | | | | |A03=[[ECG]] }} | |||
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{{familytree | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| }} | |||
{{familytree | | C01 | | D01 | | D03 | | D05 | | C03 | | C01=[[STEMI]]|D01=Diffuse ST elevation consistent with [[pericarditis]]|D03=ST-depression,New T-wave inversion|D05=Non diagnostic or normal [[ECG]]|C03=New [[arrhythmia]]}} | |||
{{Family tree| | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | }} | |||
{{Family tree| | |b1 | | b2| |b3 | |b4 | |b5 | |b1=Approach to [[STEMI]] |b2=Management of [[pericarditis]] | b3= Approach to [[NSTEMI]]|b4= | |||
*Repear [[ECG]] in the presence of persistent [[symptoms]] or change or elevated [[troponin]] level | |||
* Considering Leads V7-V9 in suspicion of posterior [[MI]] |b5=Approach to [[arrhythmia]] | | | | | | | | | | | | | }} | |||
{{familytree/end}} | |||
*'''According to the suspected etiology of the chest pain:''' | *'''According to the suspected etiology of the chest pain:''' | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2]
Overview
The diagnostic work-up of chest pain depend on the cause and as well as their hemodynamic status.The first decision point for most physicians is to determine that chest pain is caused by coronary ischemia or not. There is no single diagnostic study of choice for the diagnosis of chest pain caused by acute coronary syndrome, however ECG and cardiac enzymes are the most important initial test. ECG,Transthoracic echocardiography,Chest X-ray is recommended in all patients with suspected acute pericarditis. Chest X-ray is the gold standard test for the diagnosis of pneumothorax or pneumonia.
Diagnostic Study of Choice
| Chest pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| History, physical exam | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ECG | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| STEMI | Diffuse ST elevation consistent with pericarditis | ST-depression,New T-wave inversion | Non diagnostic or normal ECG | New arrhythmia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Approach to STEMI | Management of pericarditis | Approach to NSTEMI | *Repear ECG in the presence of persistent symptoms or change or elevated troponin level
| Approach to arrhythmia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
- According to the suspected etiology of the chest pain:
- There is no single diagnostic study of choice for the diagnosis of chest pain caused by acute coronary syndrome, however ECG and cardiac enzymes are the most important initial test, Guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) suggest the ECG be obtained and interpreted within 10 minutes of patient presentation in the ED.[1][2][3]
- The following result of ECG is confirmatory of Myocardial infarction in addition to the Pain described as a substernal pressure or crushing sensation radiated to the left arm, neck and/or jaw:
- ST- T wave changes, OR
- New LBBB, OR
- New Q wave
- The following result of ECG is confirmatory of Myocardial infarction in addition to the Pain described as a substernal pressure or crushing sensation radiated to the left arm, neck and/or jaw:
- There is no single diagnostic study of choice for the diagnosis of chest pain caused by acute coronary syndrome, however ECG and cardiac enzymes are the most important initial test, Guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) suggest the ECG be obtained and interpreted within 10 minutes of patient presentation in the ED.[1][2][3]
- Chest pain caused by pericarditis:[4]
- ECG is recommended in all patients with suspected acute pericarditis.
- Transthoracic echocardiography is recommended in all patients with suspected acute pericarditis.
- Chest X-ray is recommended in all patients with suspected acute pericarditis.
- Assessment of markers of inflammation (i.e. CRP) and myocardial injury (i.e. CK, troponin) is recommended in patients with suspected acute pericarditis. read more about recommendations for the general diagnostic work-up of pericardial diseases,here.
- Chest X-ray is the gold standard test for the diagnosis of pneumothorax or pneumonia.[5] You can read more about diagnostic criteria for severe community acquired pneumonia in adults, here.
- Order a chest X-ray if the patient presents with any of the following:
- Fever (>37.8° C / 100° F)
- Tachypnea (> 20 breaths/min)
- Tachycardia (> 100 bpm)
- Decreased breath sounds and crackles in the physical exam.
- Order a chest X-ray if the patient presents with any of the following:
- Echocardiography is the best test for the diagnosis and assessment of the severity of aortic stenosis.[6]
- Chest pain caused by aortic dissection CT scan, MRI, and trans-esophageal echocardiography have been observed to have similar reliability in the diagnosis of aortic dissection. However, CT and MRI are preferred modality for:[7][8]
- Assessing the extension and branch involvement in aortic dissection
- Diagnosing other types of acute aortic syndrome other than dissection as well as traumatic aortic lesions.
- Diagnosis of pulmonary embolism based on signs and symptoms is difficult ,however the physician can use the Wells criteria to estimate the patient's likelihood of pulmonary embolism and accordingly further testing should be performed (e.g., d-dimer assay, ventilation-perfusion scan, helical computed tomography of the pulmonary arteries).[9][10] You can read more about diagnostic criteria for pulmonary embolism, here.
- The diagnosis of GERD is mainly diagnosed based on the presence of acidic reflux in the esophagus through the ambulatory reflux monitoring.
References
- ↑ "2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 127 (23): e663–e828. 2013. doi:10.1161/CIR.0b013e31828478ac. ISSN 0009-7322.
- ↑ Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE; et al. (2012). "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 60 (7): 645–81. doi:10.1016/j.jacc.2012.06.004. PMID 22809746.
- ↑ Montalescot, G.; Sechtem, U.; Achenbach, S.; Andreotti, F.; Arden, C.; Budaj, A.; Bugiardini, R.; Crea, F.; Cuisset, T.; Di Mario, C.; Ferreira, J. R.; Gersh, B. J.; Gitt, A. K.; Hulot, J.-S.; Marx, N.; Opie, L. H.; Pfisterer, M.; Prescott, E.; Ruschitzka, F.; Sabate, M.; Senior, R.; Taggart, D. P.; van der Wall, E. E.; Vrints, C. J. M.; Zamorano, J. L.; Achenbach, S.; Baumgartner, H.; Bax, J. J.; Bueno, H.; Dean, V.; Deaton, C.; Erol, C.; Fagard, R.; Ferrari, R.; Hasdai, D.; Hoes, A. W.; Kirchhof, P.; Knuuti, J.; Kolh, P.; Lancellotti, P.; Linhart, A.; Nihoyannopoulos, P.; Piepoli, M. F.; Ponikowski, P.; Sirnes, P. A.; Tamargo, J. L.; Tendera, M.; Torbicki, A.; Wijns, W.; Windecker, S.; Knuuti, J.; Valgimigli, M.; Bueno, H.; Claeys, M. J.; Donner-Banzhoff, N.; Erol, C.; Frank, H.; Funck-Brentano, C.; Gaemperli, O.; Gonzalez-Juanatey, J. R.; Hamilos, M.; Hasdai, D.; Husted, S.; James, S. K.; Kervinen, K.; Kolh, P.; Kristensen, S. D.; Lancellotti, P.; Maggioni, A. P.; Piepoli, M. F.; Pries, A. R.; Romeo, F.; Ryden, L.; Simoons, M. L.; Sirnes, P. A.; Steg, P. G.; Timmis, A.; Wijns, W.; Windecker, S.; Yildirir, A.; Zamorano, J. L. (2013). "2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery disease of the European Society of Cardiology". European Heart Journal. 34 (38): 2949–3003. doi:10.1093/eurheartj/eht296. ISSN 0195-668X.
- ↑ Tomkowski, Witold; Swedberg, Karl; Seferovic, Petar; Sabaté Tenas, Manel; Ristić, Arsen D; Pavie, Alain; Mayosi, Bongani; Maisch, Bernhard; Lionis, Christos; Klingel, Karin; Gueret, Pascal; Brucato, Antonio; Bogaert, Jan; Barón-Esquivias, Gonzalo; Badano, Luigi; Imazio, Massimo; Charron, Philippe; Adler, Yehuda; Achenbach, Stephan; Agewall, Stefan; Al-Attar, Nawwar; Angel Ferrer, Juan; Arad, Michael; Asteggiano, Riccardo; Bueno, Héctor; Caforio, Alida L P; Carerj, Scipione; Ceconi, Claudio; Evangelista, Arturo; Flachskampf, Frank; Giannakoulas, George; Gielen, Stephan; Habib, Gilbert; Kolh, Philippe; Lambrinou, Ekaterini; Lancellotti, Patrizio; Lazaros, George; Linhart, Ales; Meurin, Philippe; Nieman, Koen; Piepoli, Massimo F; Price, Susanna; Roos-Hesselink, Jolien; Roubille, François; Ruschitzka, Frank; Sagristà Sauleda, Jaume; Sousa-Uva, Miguel; Uwe Voigt, Jens; Luis Zamorano, Jose; Zamorano, Jose Luis; Aboyans, Victor; Achenbach, Stephan; Agewall, Stefan; Badimon, Lina; Barón-Esquivias, Gonzalo; Baumgartner, Helmut; Bax, Jeroen J; Bueno, Héctor; Carerj, Scipione; Dean, Veronica; Erol, Çetin; Fitzimons, Donna; Gaemperli, Oliver; Kirchhof, Paulus; Kolh, Philippe; Lancellotti, Patrizio; Lip, Gregory YH; Nihoyannopoulos, Petros; Piepoli, Massimo F; Ponikowski, Piotr; Roffi, Marco; Torbicki, Adam; Vaz Carneiro, Antonio; Windecker, Stephan; Shuka, Naltin; Sisakian, Hamayak; Mascherbauer, Julia; Isayev, Elnur; Shumavets, Vadim; Van Camp, Guy; Gatzov, Plamen; Hanzevacki, Jadranka Separovic; Moustra, Hera Heracleous; Linhart, Ales; Møller, Jacob Eifer; Aboleineen, Mohamed Wafaie; Põder, Pentti; Lehtonen, Jukka; Antov, Slobodan; Damy, Thibaud; Schieffer, Bernhard; Dimitriadis, Kyriakos; Kiss, Robert Gabor; Rafnsson, Arnar; Arad, Michael; Novo, Salvatore; Mirrakhimov, Erkin; Stradinš, Peteris; Kavoliuniene, Ausra; Codreanu, Andrei; Dingli, Philip; Vataman, Eleonora; El Hattaoui, Mustapaha; Samstad, Stein Olav; Hoffman, Piotr; Lopes, Luís Rocha; Dimulescu, Doina Ruxandra; Arutyunov, Grigory P; Pavlovic, Milan; Dúbrava, Juraj; Sauleda, Jaume Sagristà; Andersson, Bert; Müller, Hajo; Bouma, Berto J; Abaci, Adnan; Archbold, Andrew; Nesukay, Elena (2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases". European Heart Journal. 36 (42): 2921–2964. doi:10.1093/eurheartj/ehv318. ISSN 0195-668X.
- ↑ Mandell, Lionel A.; Wunderink, Richard G.; Anzueto, Antonio; Bartlett, John G.; Campbell, G. Douglas; Dean, Nathan C.; Dowell, Scott F.; File, Thomas M.; Musher, Daniel M.; Niederman, Michael S.; Torres, Antonio; Whitney, Cynthia G. (2007). "Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults". Clinical Infectious Diseases. 44 (Supplement_2): S27–S72. doi:10.1086/511159. ISSN 1537-6591.
- ↑ Silvia Aguiar Rosa, Luisa Moura Branco, Ana Galrinho, Guilherme Portugal, Joao Abreu, Duarte Cacela, Jose Fragata & Rui Cruz Ferreira (2016). "Contribution of Dobutamine Stress Echocardiography to the Diagnosis and Prognosis of Low-Flow/Low-Gradient Aortic Stenosis". The Journal of heart valve disease. 25 (2): 130–138. PMID 27989054. Unknown parameter
|month=ignored (help) - ↑ Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y (July 2006). "Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis". Arch. Intern. Med. 166 (13): 1350–6. doi:10.1001/archinte.166.13.1350. PMID 16831999.
- ↑ Quint LE, Francis IR, Williams DM, Bass JC, Shea MJ, Frayer DL, Monaghan HM, Deeb GM (October 1996). "Evaluation of thoracic aortic disease with the use of helical CT and multiplanar reconstructions: comparison with surgical findings". Radiology. 201 (1): 37–41. doi:10.1148/radiology.201.1.8816517. PMID 8816517.
- ↑ Wells, Philip S.; Anderson, David R.; Rodger, Marc; Stiell, Ian; Dreyer, Jonathan F.; Barnes, David; Forgie, Melissa; Kovacs, George; Ward, John; Kovacs, Michael J. (2001). "Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and d-dimer". Annals of Internal Medicine. 135 (2): 98. doi:10.7326/0003-4819-135-2-200107170-00010. ISSN 0003-4819.
- ↑ Tamariz, Leonardo J.; Eng, John; Segal, Jodi B.; Krishnan, Jerry A.; Bolger, Dennis T.; Streiff, Michael B.; Jenckes, Mollie W.; Bass, Eric B. (2004). "Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: A systematic review". The American Journal of Medicine. 117 (9): 676–684. doi:10.1016/j.amjmed.2004.04.021. ISSN 0002-9343.