Initial Approach to the patient with Chest pain

Chest pain is one of the most feared symptoms in primary care. While the priority in any patient who presents with chest pain is to exclude catastrophic or life-threatening (cardiac) causes, non-life-threatening etiologies, which may be functionally disabling, are much more common in the primary care setting and require a cost-effective approach to diagnosis. The correct diagnosis is most often derived from a detailed history that is supported by specific physical findings, an electrocardiogram, and/or chest x-ray.

Causes of chest pain in the outpatient clinic
(See Table 1).
The prevalence of chest pain etiologies varies according to the population studied. The presence of risk factors and the age of the patient population are important contributors to coronary artery disease (CAD) prevalence. (See Chapter on Overview of the Risk Factors for Cardiovascular Disease- DFH-IM-50).

Emergency response to chest pain in the outpatient clinic
Chest pain due to myocardial infarction, pulmonary embolus, aortic dissection, or tension pneumothorax may result in sudden death. Any patient with a recent onset of chest pain, especially when the symptoms are ongoing, who may be potentially unstable based upon history, appearance, or vital signs, should be transported immediately to an emergency department preferably in an ambulance equipped with a defibrillator. Stabilization of such patients should begin in the prehospital setting and includes supplemental oxygen, intravenous access, and placement of a cardiac monitor. A 12-lead electrocardiogram should be obtained if possible. Patients who are thought to be experiencing a myocardial infarction should chew a 325 mg aspirin tablet. Sublingual nitroglycerin should be withheld if the patient has relatively low blood pressure without intravenous access or has recently taken sildenafil (Viagra).

Evaluation of patients with chest pain
The initial goal in the office evaluation of chest pain in stable individuals is to exclude CAD and other potentially life-threatening conditions. The history and physical examination, complemented by selected tests such as an electrocardiogram or chest radiograph, allow the physician to accurately diagnose most causes of chest pain, especially CAD, and to judge which patients likely have a benign etiology. The need for a good history and physical examination is emphasized by the fact that, the accuracy of the clinical examination for determining the presence of CAD is improved only marginally, if at all, by exercise testing. In a study which found that the predictive accuracy for CAD using clinical factors was 84 percent; inclusion of exercise test results increased the predictive accuracy to only 87 percent.


ossiva06, India

my father is suffering from chest pain . which doctor i want to consult in chennai

Edphil, United Kingdom

I have a right side chest pain that radiates to the arm.I have been feeling this pain in a dull manner for more than six months now but the radiation to the arm started recently.I have been for a chest x-ray and waiting for the result.The pain goes off temporarily if I indulge in exercise for more than 30 minutes but comes back in the morning.Today it was persistent that I can hardly raise my right arm or carry my baby.I am waiting for the test result before I get back to the GP.Please tell me what to do.

shaanZee, India

my husband age 33 has a pain in chest from few days if he walk fast

MandarS, India

Recently I Lost my mother by heart attached on 21.09.2010, she got chest pain at 10.30pm I call doctor near to me (BAMS) she miss guide me that chest pain due to acidity becouse my mother BP and heart beat is normal at that time and chest pain is in centre part of chest as inform by that doctor.

Still for safer side we moved her to cardiologst he take ECG & infor its start of heart attack, he gave her sorbitol & some liquid syrup & asked to move to ICCU.
I call abilance from Wackharts but during trasit she got attack and she pass away.

The mistake we have done,
Loss the time to investigate reason of chest pain
Suggession :-
Do not wait to invetigate rason for chest pain, just move to the hospital who can investigate & treat the chest pain reason whatever maybe.

nancyk, United States

I have chest pain on the right side and in right arm. Chest Pain started early morning before sun came up. Right arm started around lunch time. Should I go to emergency room?