Chest pain diagnostic study of choice
|
Chest pain Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Chest pain diagnostic study of choice On the Web |
|
Risk calculators and risk factors for Chest pain diagnostic study of choice |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2]
Overview
Chest pain or chest pain equivalent nay be referred as chest pain. Patients presenting to the ED with nontraumatic chest pain are a frequent diagnostic challenge. Initial evaluation is considered for life-threatening conditions such as ACS, aortic dissection, and pulmonary embolism , as well as nonvascular syndromes (eg, esophageal rupture, tension pneumothorax). So, therapy for those with less critical illnesses is reasonable. Although there are several life-threatening causes, chest pain usually reflects a more benign condition. The initial ECG is important to the evaluation, but history, physical examination, biomarkers, and other tests are necessary. There is no association between the intensity of symptoms and seriousness of disease and general similarity of symptoms among different causes of chest pain. A comprehensive history that collects all the characteristics of chest pain including nature; 2) onset and duration, 3) location and radiation, 4) precipitating factors, 5) relieving factors, and 6) associated symptoms can help better identify potential cardiac causes and should be obtained from all patients.
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 or chest pain equivalent will be referred to in these guidelines as “chest pain.” Patients presenting to the ED with nontraumatic chest pain are a frequent diagnostic challenge.1 The priorities are: 1) rapid initiation of optimal management in patients with life-threatening conditions such as ACS, aortic dissection, and pulmonary embolism (PE), as well as nonvascular syndromes (eg, esophageal rupture, tension pneumothorax); and 2) deliberate therapy for those with less critical illness. Although there are several life-threatening causes, chest pain usually reflects a more benign condition (Figure 3).2-4 The initial ECG is important to the evaluation, but history, examination, biomarkers, and other aids remain essential. There is frequently a lack of correlation between intensity of symptoms and seriousness of disease and general similarity of symptoms among different causes of chest pain. A comprehensive history that captures all the characteristics of chest pain (Table 3), including but not limited to its: 1) nature; 2) onset and duration; 3) location and radiation; 4) precipitating factors; 5) relieving factors; and 6) associated symptoms can help better identify potential cardiac causes and should be obtained from all patients.
| Recommendations for diagnostic tests of chest pain |
| ECG (class 1 ) |
|
❑ ECG is recommended in patients presenting with stable chest pain, unless in the evidence of noncardiac causes |
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
|---|
Diagnostic algorythm based on the ECG
| 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 NSTE-ACS | *Repear ECG in the presence of persistent symptoms or change or elevated troponin level
| Approach to arrhythmia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
|---|
Algorithm for evaluation of suspected ACS with intermediate risk and NO history of coronary artery disease
Abbreviations: Recent negative test: Normal CCTA ≤ 2 years (no plaque, no stenosis) or negative stress test≤ 1 year ; High risk CAD: Left main stenosis ≥ 50%; significant three vessel disease (stenosis ≥ 70%) CAD: Coronary artery disease ; CCTA: Coronary CT angiography; FFR-CT: Fractional flow reserve with CT; PET: Positron emission tomography; SPECT: Single-photon emission CT; INOCA: schemia and no obstructive coronary artery disease; CMR: Cardiovascular magnetic resonance imaging; CT:Computed tomography
| Acute chest pain, intermediate risk, No known CAD | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Perior testing | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stress testing
| Coronary CT angiography | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Recent negative test | Perior inconclusive or mildly abnormal stress test ≤ 1 year | Moderate severely abnormal test ≤ 1 year | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discharge | Coronary CT angiography (2a) | Invasive coronary angiography | Non obstructive CAD (stenosis<50%)= Discharge | Inconclusive stenosis | Obstructive CAD (stenosis)≥ 50% | High risk CAD or frequent angina=Coronary angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Non obstructive CAD (stenosis<50%) | Inconclusive result | Obstructive CAD (stenosis ≥ 50%) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| FFR-CT, or stress testing | Medical therapy, discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discharge | FFR-CT or stress test (2a) | *High risk CAD, frequent angina= Coronary angiography
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| FFR-CT≤0.8, moderate to severe ischemia=Coronary angiography | FFR-CT>0.8, mild ischemia= medical therapy, discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| FFR-CT ≤ 0.8 , moderate severely ischemia=Coronary angiography | FFR-CT>0.8, mild ischemia=Medical therapy, discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Negative or mildly abnormal=discharge | Moderately severe ischemia= Coronary angiography | Inconclusive=Coronary CT angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
|---|
Approach to patients with acute chest pain
| Patient with acute chest pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| History, physical exam | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ECG | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Consider non cardiac cause | Consider nonischemic cardiac cause | Possible ACS | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| NO cardiac testing needed | Other cardiac testing as required | Obtain troponin | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Risk stratification by clinical condition evaluation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Low risk | Intermediate risk | High risk | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| NO testing required, discharge | Further diagnostic test may be needed | Invasive coronary angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
|---|
- 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.
- 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.
- Chest pain caused by pericarditis:[2]
- 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.[3] 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.[4]
- 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:[5][6]
- 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).[7][8] 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
- ↑ 1.0 1.1 1.2 1.3 Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check
|pmid=value (help). - ↑ 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.