Physical Examination & Diagnostic Testing in Patients with Chest Pain

Physical Examination

Causes of chest pain are numerous; the initial evaluation should focus on those that are life-threatening, such as ACS, PE, aortic dissection, and esophageal rupture, to facilitate rapid implementation of appropriate treatment. Specific clues can be helpful. Chest tenderness on palpation or pain with inspiration markedly reduces the probability of ACS. Integrating the examination with other elements of the evaluation is crucial to establishing the correct diagnosis.

Clinical Syndrome	Findings
Emergency
ACS	Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, MR murmur.²; examination may be normal in uncomplicated cases
PE	Tachycardia + dyspnea—>90% of patients; pain with inspiration⁷
Aortic dissection	Connective tissue disorders (eg, Marfan syndrome), extremity pulse differential (30% of patients, type A>B)⁸ Severe pain, abrupt onset + pulse differential + widened mediastinum on CXR >80% probability of dissection⁹ Frequency of syncope >10%⁸, AR 40%–75% (type A)¹⁰
Esophageal rupture	Emesis, subcutaneous emphysema, pneumothorax (20% patients), unilateral decreased or absent breath sounds
Other
Noncoronary cardiac: AS, AR, HCM	AS: Characteristic systolic murmur, tardus or parvus carotid pulse AR: Diastolic murmur at right of sternum, rapid carotid upstroke HCM: Increased or displaced left ventricular impulse, prominent a wave in jugular venous pressure, systolic murmur
Pericarditis	Fever, pleuritic chest pain, increased in supine position, friction rub
Myocarditis	Fever, chest pain, heart failure, S3
Esophagitis, peptic ulcer disease, gall bladder disease	Epigastric tenderness Right upper quadrant tenderness, Murphy sign
Pneumonia	Fever, localized chest pain, may be pleuritic, friction rub may be present, regional dullness to percussion, egophony
Pneumothorax	Dyspnea and pain on inspiration, unilateral absence of breath sounds
Costochondritis, Tietze syndrome	Tenderness of costochondral joints
Herpes zoster	Pain in dermatomal distribution, triggered by touch; characteristic rash (unilateral and dermatomal distribution)

ACS indicates acute coronary syndrome; AR, aortic regurgitation; AS, aortic stenosis; CXR, chest x-ray; LR, likelihood ratio; HCM, hypertrophic cardiomyopathy; MR, mitral regurgitation; PE, pulmonary embolism; and PUD, peptic ulcer disease.

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Diagnostic Testing

Electrocardiogram

Patients with chest pain and new ST-elevation, ST depression, or new left bundle branch block on ECG should be treated according to STEMI and NSTE-ACS guidelines.

An initial normal ECG does not exclude ACS. Patients with an initial normal ECG should have a repeat ECG, if symptoms are ongoing, until other diagnostic testing rules out ACS.

Algorithm for the role of the ECG to help direct care for individuals presenting with chest pain or chest pain equivalents.

Figure. Electrocardiographic-Directed Management of Chest Pain

ECG indicates electrocardiogram; MI, myocardial infarction; NSTE-ACS, non–ST-segment–elevation acute coronary syndrome; and STEMI, ST-segment–elevation myocardial infarction.

In patients where the initial ECG is normal or is without ST elevation, hyperacute T waves, left bundle branch block, or ST depression, serial ECGs should be performed and management should be guided by new electrocardiographic changes or other diagnostic testing (Biomarkers, Anatomic Testing, Stress Testing).

A normal ECG may be associated with left circumflex or right coronary artery occlusions and posterior wall ischemia, which is often “electrically silent”; therefore, right-sided ECG leads should be considered when such lesions are suspected

Chest Radiography

Chest radiographs are rapid, noninvasive tests that can be used to screen for several disorders that may present with chest pain.

The AHA/ACC guidelines for NSTE-ACS and heart failure all recommend chest radiographs on presentation, although this should not delay urgent revascularization if it is indicated.

Biomarkers

Cardiovascular biomarkers can be useful for the diagnostic and prognostic assessment of patients with chest pain. Their most important application in clinical practice is for the rapid identification or exclusion of myocardial injury.

The preferred biomarker to detect or exclude myocardial injury is cTn (I or T) because of its high sensitivity and specificity for myocardial tissue. hs-cTn is preferred and can detect circulating cTn in the blood of most “healthy” individuals, with different sex-specific thresholds.

cTn is organ-specific but not disease-specific. Numerous ischemic, noncoronary cardiac, and noncardiac causes of cardiomyocyte injury can result in elevated cTn concentrations. Therefore, interpretation of cTn results requires integration with all clinical information.

Comparative studies have confirmed the superiority of cTn over CK-MB and myoglobin for diagnosis and prognosis of AMI. The addition of CK-MB or myoglobin to cTn for evaluation of patients presenting with chest pain is not beneficial.

cTn: Cardiac Troponin, hs-cTn: High Sensitive Cardiac Troponin