Acute chest pain

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See Acute coronary syndrome (main) for ACS specific workup and risk stratification; see Chest pain (peds) for pediatric patients.

Background

Clinical Features

Risk of ACS

Clinical factors that increase likelihood of ACS/AMI:[1][2]

Clinical factors that decrease likelihood of ACS/AMI:[3]

  • Pleuritic chest pain
  • Positional chest pain
  • Sharp, stabbing chest pain
  • Chest pain reproducible with palpation

Gender differences in ACS

  • Women with ACS are less likely to be treated with guideline-directed medical therapies, less likely to undergo cardiac catheterization, and less likely to receive timely reperfusion.[4]
  • Men are more likely to report central chest pain, while women are more likely to report fatigue, dyspnea, indigestion, nausea/vomiting, palpitations and weakness[5], although some studies have found fewer differences in presentation[6]
  • Women are more likely to delay presentation. Additional factors associated with delay in seeking treatment include older age, Black or Hispanic race, and lower education and socioeconomic levels.[7]

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Evaluation

Workup

Younger patients/less concerning story

Older patients/more concerning story

Diagnosis

Consider differential diagnosis (see above) and rule out emergent causes

Management

  • Based on underlying cause

Disposition

  • Based on underlying cause

See Also

Video

References

  1. Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454
  2. Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377
  3. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077
  4. Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.
  5. Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.
  6. Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.
  7. Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.