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Chest pain leads to about 4 million outpatient visits per year and is the second most common reason for emergency department care, with nearly 7 million visits per year. Although most chest pain is noncardiac, more than 18 million people in the United States have coronary artery disease (CAD), leading to more than 1,000 deaths per day. The American Heart Association/American College of Cardiology (AHA/ACC) updated guidelines for management of chest pain, which are endorsed by five other cardiology groups. The guidelines provide new recommendations on what to consider chest pain and when to avoid testing in patients at low risk, and they endorse use of published decision pathways to determine the order and extent of workup.
Initial Evaluation
Chest pain can present as pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw and less commonly as shortness of breath, nausea, or fatigue without pain. Chest pain is considered acute with new onset or if it involves a change in pattern, intensity, or duration; it is considered stable if it is chronic with unchanging triggers such as exertion or emotional stress. Patients commonly describe ischemic chest pain as pressure, squeezing, heaviness, tightness, exertional, stress-related, or retrosternal. Pain that is sharp, fleeting, pleuritic, positional, or shifting locations is less likely to be of cardiac origin. These guidelines suggest describing chest pain as cardiac; possible cardiac; or noncardiac. The descriptor atypical is no longer used because it can be interpreted by patients as being benign.
Initial evaluation should focus on ruling out life-threatening illnesses such as acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism, which are often not indicated by pain severity. Response to nitroglycerin is not an accurate means of ruling in cardiac chest pain. Patients with diabetes mellitus, women, and older patients more often present with associated nausea, fatigue, and shortness of breath. ACS should be considered when patients older than 75 years present with shortness of breath, syncope, mental impairment, or abdominal pain, or if they experience an unexplained fall.
People from ethnic and racial minorities experience delays in diagnosis of a cardiac cause and treatment of chest pain. A higher proportion of Black patients presenting with chest pain have a cardiac etiology, but they are...