Approach to the Patient with Chest Pain

  • Benjamin R. McClintic
  • Robert L. Rosenblatt


Despite significant advances in both diagnostic and therapeutic modalities in the last few decades, a chief complaint of chest pain still presents the clinician with a challenging management situation. Chest pain can indicate serious and immediately life-threatening underlying pathology but can also be due to common and benign processes. This dichotomy makes prompt and accurate identification of chest pain etiologies important from patient care, medical-legal, and cost-effectiveness standpoints.


Chest Pain Acute Coronary Syndrome Acute Myocardial Infarction Coronary Artery Calcium Aortic Dissection 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Niska R, Bhuiya F, Xu J. National hospital ambulatory medical care survey: 2007 emergency department summary. Natl Health Stat Report. 2010;26:1–32.PubMedGoogle Scholar
  2. 2.
    Buntinx F, Knockaert D, Bruyninckx R, et al. Chest pain in general practice or in the hospital emergency department: is it the same? Fam Pract. 2001;18(6):586–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163–70.PubMedCrossRefGoogle Scholar
  4. 4.
    Guyton AC, Hall JE. Visceral pain. Textbook of medical physiology. 9th ed. Philadelphia: Saunders; 1996. p. 615–6.Google Scholar
  5. 5.
    Foreman RD. Mechanisms of cardiac pain. Annu Rev Physiol. 1999;61:143–67.PubMedCrossRefGoogle Scholar
  6. 6.
    Panju AA, Hemmelgar BR, Guyatt GH, Simel DL. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–63.PubMedCrossRefGoogle Scholar
  7. 7.
    Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction), developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. [published correction appears in J Am Coll Cardiol. 2008;51:974]. J Am Coll Cardiol. 2007;50:e1–157.PubMedCrossRefGoogle Scholar
  8. 8.
    Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad Emerg Med. 2002;9:203.PubMedCrossRefGoogle Scholar
  9. 9.
    Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294:2623–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Shry EA, Dacus J, Van De Graaff E, et al. Usefulness of the response to sublingual nitroglycerin as a predictor of ischemic chest pain in the emergency department. Am J Cardiol. 2002;90:1264–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection: new insights into an old disease. JAMA. 2000;283:897–903.PubMedCrossRefGoogle Scholar
  12. 12.
    Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122:1756–76.PubMedCrossRefGoogle Scholar
  13. 13.
    Lee TH, Goldman L. Evaluation of the patient with acute chest pain. NEJM. 2000;342:1187–95.PubMedCrossRefGoogle Scholar
  14. 14.
    Kontos MC, Diercks DB, Kirk JD. Emergency department and office-based evaluation of patients with chest pain. Mayo Clin Proc. 2010;85(3):284–99.PubMedCrossRefGoogle Scholar
  15. 15.
    Chan TC, Vilke GM, Pollack M, Brady WJ. Electrocardiographic manifestations: pulmonary embolism. J Emerg Med. 2001;21(3):263–70.PubMedCrossRefGoogle Scholar
  16. 16.
    Eggers KM, Oldgren J, Nordenskjold A, Lindahl B. Diagnostic value of serial measurement of cardiac markers in patients with chest pain: limited value of adding myoglobin to troponin I for exclusion of myocardial infarction. Am Heart J. 2004;148:574–81.PubMedCrossRefGoogle Scholar
  17. 17.
    Thygesen K, Alpert JS, White HD, et al. Universal definition of myocardial infarction. Circulation. 2007;116:2634–53.PubMedCrossRefGoogle Scholar
  18. 18.
    Kelley WE, Januzzi JL, Christenson RH. Increases of cardiac troponin in conditions other than acute coronary syndrome and heart failure. Clin Chem. 2009;55(12):2098–112.PubMedCrossRefGoogle Scholar
  19. 19.
    Saenger AK, Jaffe AS. The use of biomarkers for the evaluation and treatment of patients with acute coronary syndromes. Med Clin North Am. 2007;91:657–81.PubMedCrossRefGoogle Scholar
  20. 20.
    Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000;283(24):3223–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Jones ED, Slovis CM. Pitfalls in evaluating the low-risk chest pain patient. Emerg Clin North Am. 2010;28:183–201.CrossRefGoogle Scholar
  22. 22.
    Kones R. Recent advances in the management of chronic stable angina I: approach to the patient, diagnosis, pathophysiology, risk stratification, and gender disparities. Vasc Health Risk Manag. 2010;6:635–56.PubMedCrossRefGoogle Scholar
  23. 23.
    Fraker TD, Fihn SD. 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the 2002 Guidelines for the Management of Patients with Chronic Stable Angina. Circulation. 2007;116:2762–72.PubMedCrossRefGoogle Scholar
  24. 24.
    Kones R. Recent advances in the management of chronic stable angina II: anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization. Vasc Health Risk Manag. 2010;6:749–74.PubMedCrossRefGoogle Scholar
  25. 25.
    Grundy SM, Becker D, Clark LT, Cooper RS, Other Members of the National Cholesterol Education Program Expert Panel. Third report of the NCEP on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III) executive summary. Bethesda: National Heart, Lung, and Blood Institute/National Institutes of Health; 2001.Google Scholar
  26. 26.
    Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000;342:836–43.PubMedCrossRefGoogle Scholar
  27. 27.
    Ridker PM, Danielson E, Fonseca FAH, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med. 2008;359:2195–207.PubMedCrossRefGoogle Scholar
  28. 28.
    Clarke R, Peden JF, Hopewell JC, et al. Genetic variants associated with Lp(a) lipoprotein level and coronary disease. N Engl J Med. 2009;361:2518–28.PubMedCrossRefGoogle Scholar
  29. 29.
    Budoff MJ, Achenbach S, Blumenthal RS, et al. Assessment of coronary artery disease from cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation. 2006;114:1761–91.PubMedCrossRefGoogle Scholar
  30. 30.
    Braunwald E, Mark DB, Jones RH, et al. Unstable angina: diagnosis and management. Rockville: Agency for Health Care Policy and Research and the National Heart,Lung, U.S.Public Health Service, U.S. Department of Health and Human Service; 1994. AHCPR publication no 94-0602 (124).Google Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

  1. 1.Division of Cardiology, Department of MedicineUniversity of Rochester Medical CenterRochesterUSA

Personalised recommendations