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Evaluation of Chest Pain

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Abstract

The evaluation of patients with chest pain is a common task for medical practitioners. This commonly occurs in the context of an emergency department or inpatient hospital encounter and requires a comprehensive yet focused approach to provide a rapid diagnosis and assessment of risk. This chapter outlines the key elements of this evaluation: history and symptoms, physical exam, and ancillary testing, with a particular focus on imaging strategies that can be employed for the evaluation of chest pain and their use in settings such as chest pain evaluation units.

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References

  1. 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: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007;116(7):e148–304.

    Article  PubMed  Google Scholar 

  2. Henrikson CA, Howell EE, Bush DE, et al. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med. 2003;139(12):979–86.

    Article  PubMed  Google Scholar 

  3. Chaitman BR, Bourassa MG, Davis K, et al. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation. Aug 1981;64(2):360–7.

    Article  PubMed  Google Scholar 

  4. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina–summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003;107(1):149–58.

    Article  PubMed  Google Scholar 

  5. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300(24):1350–8.

    Article  PubMed  CAS  Google Scholar 

  6. Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM 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 (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol. Jun 1999;33(7):2092–197.

    Article  PubMed  Google Scholar 

  7. Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol. 1989;64(18):1087–92.

    Article  PubMed  CAS  Google Scholar 

  8. Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA Guidelines for Exercise Testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol. Jul 1997;30(1):260–311.

    PubMed  Google Scholar 

  9. Henzlova MJ, Cerqueira MD, Mahmarian JJ, Yao SS. Stress protocols and tracers. J Nucl Cardiol. Nov 2006;13(6):e80–90.

    Article  PubMed  Google Scholar 

  10. Mark DB, Hlatky MA, Harrell Jr FE, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med. Jun 1987;106(6):793–800.

    Article  PubMed  Google Scholar 

  11. Fearon WF, Lee DP, Froelicher VF. The effect of resting ST segment depression on the diagnostic characteristics of the exercise treadmill test. J Am Coll Cardiol. Apr 2000;35(5):1206–11.

    Article  PubMed  Google Scholar 

  12. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60(16):1581–98.

    Article  PubMed  Google Scholar 

  13. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet. 1999;354(9180):708–15.

    Google Scholar 

  14. Kleiman NS, Lakkis N, Cannon CP, et al. Prospective analysis of creatine kinase muscle-brain fraction and comparison with troponin T to predict cardiac risk and benefit of an invasive strategy in patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2002;40(6):1044–50.

    Article  PubMed  CAS  Google Scholar 

  15. Horowitz RS, Morganroth J, Parrotto C, Chen CC, Soffer J, Pauletto FJ. Immediate diagnosis of acute myocardial infarction by two-dimensional echocardiography. Circulation. Feb 1982;65(2):323–9.

    Article  PubMed  Google Scholar 

  16. Peels CH, Visser CA, Kupper AJ, Visser FC, Roos JP. Usefulness of two-dimensional echocardiography for immediate detection of myocardial ischemia in the emergency room. Am J Cardiol. 1990;65(11):687–91.

    Article  PubMed  CAS  Google Scholar 

  17. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance: endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. Circulation. 2008;117(11):1478–97.

    Article  PubMed  Google Scholar 

  18. Geleijnse ML, Elhendy A. Can stress echocardiography compete with perfusion scintigraphy in the detection of coronary artery disease and cardiac risk assessment? Eur J Echocardiogr. Mar 2000;1(1):12–21.

    Article  PubMed  Google Scholar 

  19. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52(21):1724–32.

    Article  PubMed  Google Scholar 

  20. Min JK, Dunning A, Lin FY, et al. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol. 2011;58(8):849–60.

    Article  PubMed  Google Scholar 

  21. Taylor AJ, Cerqueira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2010;56(22):1864–94.

    Article  PubMed  Google Scholar 

  22. Hilton TC, Thompson RC, Williams HJ, Saylors R, Fulmer H, Stowers SA. Technetium-99m sestamibi myocardial perfusion imaging in the emergency room evaluation of chest pain. J Am Coll Cardiol. Apr 1994;23(5):1016–22.

    Article  PubMed  Google Scholar 

  23. Hilton TC, Fulmer H, Abuan T, Thompson RC, Stowers SA. Ninety-day follow-up of patients in the emergency department with chest pain who undergo initial single-photon emission computed tomographic perfusion scintigraphy with technetium 99m-labeled sestamibi. J Nucl Cardiol. 1996;3(4):308–11.

    Article  PubMed  CAS  Google Scholar 

  24. Varetto T, Cantalupi D, Altieri A, Orlandi C. Emergency room technetium-99m sestamibi imaging to rule out acute myocardial ischemic events in patients with nondiagnostic electrocardiograms. J Am Coll Cardiol. Dec 1993;22(7):1804–8.

    Article  PubMed  Google Scholar 

  25. Heller GV, Stowers SA, Hendel RC, et al. Clinical value of acute rest technetium-99m tetrofosmin tomographic myocardial perfusion imaging in patients with acute chest pain and nondiagnostic electrocardiograms. J Am Coll Cardiol. Apr 1998;31(5):1011–7.

    Article  PubMed  Google Scholar 

  26. Dorbala S, Hachamovitch R, Curillova Z, et al. Incremental prognostic value of gated Rb-82 positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF. JACC Cardiovasc Imaging. Jul 2009;2(7):846–54.

    Article  PubMed  Google Scholar 

  27. Nandalur KR, Dwamena BA, Choudhri AF, Nandalur SR, Reddy P, Carlos RC. Diagnostic performance of positron emission tomography in the detection of coronary artery disease: a meta-analysis. Acad Radiol. Apr 2008;15(4):444–51.

    Article  PubMed  Google Scholar 

  28. Bateman TM, Heller GV, McGhie AI, et al. Diagnostic accuracy of rest/stress ECG-gated Rb-82 myocardial perfusion PET: comparison with ECG-gated Tc-99m sestamibi SPECT. J Nucl Cardiol. 2006;13(1):24–33.

    Article  PubMed  Google Scholar 

  29. El Fakhri G, Kardan A, Sitek A, et al. Reproducibility and accuracy of quantitative myocardial blood flow assessment with (82)Rb PET: comparison with (13)N-ammonia PET. J Nucl Med. Jul 2009;50(7):1062–71.

    Article  PubMed  Google Scholar 

  30. Depuey EG, Mahmarian JJ, Miller TD, et al. Patient-centered imaging. J Nucl Cardiol. Apr 2012;19(2):185–215.

    Article  PubMed  Google Scholar 

  31. Brown KA. Do stress echocardiography and myocardial perfusion imaging have the same ability to identify the low-risk patient with known or suspected coronary artery disease? Am J Cardiol. 1998;81(8):1050–3.

    Article  PubMed  CAS  Google Scholar 

  32. Brown KA. Prognostic value of thallium-201 myocardial perfusion imaging. A diagnostic tool comes of age. Circulation. 1991;83(2):363–81.

    Article  PubMed  CAS  Google Scholar 

  33. Iskandrian AE, Verani MS. Nuclear cardiac imaging: principles and applications. 3rd ed. New York: Oxford University Press; 2003.

    Google Scholar 

  34. American College of Emergency Physicians. State of the Art: Observation Units in the Emergency Department. Policy Resource and Education Paper. 2011; http://www.acep.org/Search.aspx?searchtext=chest+pain&folderId=2144&isRecursive=True. Accessed 6 Apr 2012.

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Correspondence to Edward J. Miller MD, PhD .

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© 2014 Springer-Verlag London

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Miller, E.J. (2014). Evaluation of Chest Pain. In: Stergiopoulos, K., Brown, D. (eds) Evidence-Based Cardiology Consult. Springer, London. https://doi.org/10.1007/978-1-4471-4441-0_1

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  • DOI: https://doi.org/10.1007/978-1-4471-4441-0_1

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