Chest pain—tools to improve your in-office evaluation

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Applied Evidence

Chest pain—tools to improve your in-office evaluation

J Fam Pract. 2014 May;63(5):246-251

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References

1. Amsterdam EA, Kirk JD, Bluemke DA, et al; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122:1756-7176.

2. Bhuiya FA, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999-2008. NCHS Data Brief. 2010;43:1-8.

3. Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract. 1994;38:345-352.

4. McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87:177-82.

5. Nilsson S, Scheike M, Engblom D, et al. Chest pain and ischaemic heart disease in primary care. Br J Gen Pract. 2003;53:378-382.

6. 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;18:586-589.

7. Jonsbu E, Dammen T, Morken G, et al. Cardiac and psychiatric diagnoses among patients referred for chest pain and palpitations. Scand Cardiovasc J. 2009;43:256-259.

8. O’Connor RE, Brady W, Brooks SC, et al. Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S787-S817.

9. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294:2623-2629.

10. Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280:1256-1263.

11. Bruyninckx R, Aertgeerts B, Bruyninckx P, et al. Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis. Br J Gen Pract. 2008;58:105-111.

12. Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ. 2010;182:1295-1300.

13. Haasenritter J, Bösner S, Vaucher P, et al. Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule. Br J Gen Pract. 2012;62:e415-e421.

14. Bösner S, Becker A, Hani MA, et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Fam Pract. 2010;27:363-369.

15. Verdon F, Burnand B, Herzig L, et al. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract. 2007;8:51.

16. Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80:617-620.

17. Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. 2009;31:169-171.

18. Lacy BE, Weiser K, Chertoff J, et al. The diagnosis of gastroesophageal reflux disease. Am J Med. 2010;123: 583-592.

19. Wang WH, Huang JQ, Zheng GF, et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a metaanalysis. Arch Intern Med. 2005;165:1222-1228.

20. Pandak WM, Arezo S, Everett S, et al. Short course of omeprazole: a better first diagnostic approach to noncardiac chest pain than endoscopy, manometry, or 24-hour esophageal pH monitoring. J Clin Gastroenterol. 2002;35:307-314.

21. Xia HH, Lai KC, Lam SK, et al. Symptomatic response to lansoprazole predicts abnormal acid reflux in endoscopy-negative patients with non-cardiac chest pain. Aliment Pharmacol Ther. 2003;17:369-377.

22. Flook NW, Moayyedi P, Dent J, et al. Acid-suppressive therapy with esomeprazole for relief of unexplained chest pain in primary care: a randomized, double-blind, placebo-controlled trial. Am J Gastroenterol. 2013;108:56-64.

23. Stein MB, Roy-Byrne PP, McQuaid JR, et al. Development of a brief diagnostic screen for panic disorder in primary care. Psychosom Med. 1999;61:359-364.

24. Ballenger JC. Treatment of panic disorder in the general medical setting. J Psychosom Res. 1998;44:5-15.

25. Dammen T, Ekeberg O, Arnesen H, et al. The detection of panic disorder in chest pain patients. Gen Hosp Psychiatry. 1999;21:323-332.

26. Kisely SR, Campbell LA, Yelland MJ, et al. Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy. Cochrane Database Syst Rev. 2012;6:CD004101.

27. Ruigómez A, Rodríguez LA, Wallander MA, et al. Chest pain in general practice: incidence, comorbidity and mortality. Fam Pract. 2006;23:167-174.

28. Ruigómez A, Massó-González EL, Johansson S, et al. Chest pain without established ischaemic heart disease in primary care patients: associated comorbidities and mortality. Br J Gen Pract. 2009;59:e78-e86.

29. Hermann LK, Newman DH, Pleasant WA, et al. Yield of routine provocative cardiac testing among patients in an emergency department-based chest pain unit. JAMA Intern Med. 2013;173:1128-1133.

Marburg Heart Score and other tests can help rule out ACS

Patients with chest pain that is exertional, radiating to one or both arms, or associated with nausea are at high risk for acute coronary syndrome.As part of your initial physical examination, assess the patient’s overall condition and stability. Be aware, however, that an older literature review found that a physical exam is only minimally helpful in assessing ACS risk in a patient with chest pain. Findings that may increase the risk of ACS are a third heart sound (positive likelihood ratio [LR+] = 3.2; 95% confidence interval [CI], 1.6-6.5), systolic blood pressure <80 mm/Hg (LR+ = 3.1; 95% CI, 1.8-5.2), and pulmonary crackles on auscultation (LR+ = 2.1; 95% CI, 1.4–3.1); however, the absence of these findings does not exclude ACS.10 The most helpful sign or symptom in evaluating a patient with chest pain is chest wall tenderness on palpation, which largely rules out ACS in low-prevalence settings, such as a primary care office.¹¹

Bösner et al¹² developed the Marburg Heart Score (MHS) to help primary care physicians evaluate the risk of CAD in patients with chest pain (TABLE 3).^12,13 A subsequent validation study found that an MHS ≥3 had a sensitivity of 89.1% (95% CI, 81.1%-94%) and a specificity of 63.5% (95% CI, 60%-66.9%) for CAD.¹³ The test’s negative predictive value (NPV) of 97.9% (95% CI, 96.2%-98.9%) means that patients with an MHS ≤2 are very unlikely to have CAD; however, the low positive predictive value (PPV) of only 23.3% (95% CI, 19.2%-28.0%) means an MHS ≥3 is not particularly helpful in diagnosing CAD.^12,13

Unless it is clear that your patient’s chest pain is unlikely to have a cardiac cause (eg, pain is reproducible on palpation, or an MHS ≤2), order an electrocardiogram (EKG). If the EKG shows ST-segment elevation in 2 or more contiguous leads, presumed new left bundle branch block, ischemic ST-segment depression >.5 mm (.05 mV), or dynamic T-wave inversion with pain or discomfort, the patient needs urgent referral for emergency care.⁸ If the EKG is nondiagnostic but the chest pain is suspicious for CAD, then further testing with cardiac biomarkers (eg, troponin I or T) is recommended to evaluate for non-ST elevation myocardial infarction. Consider chest radiography if there is evidence of respiratory disease (cough, dyspnea, or a history of pulmonary disease).

Don’t overlook chest wall syndrome, GERD, or panic disorder

There are several conditions to consider in the differential diagnosis of patients whose chest pain does not appear to have a cardiac cause:

CWS is the most common cause of chest pain in primary care patients.^14,15 While there are several specific types of chest wall pain—including musculoskeletal pain, parietal or intercostal pain, Tietze’s syndrome, and costochondral pain—all are manifestations of a musculoskeletal disorder and associated with tenderness of the chest wall. CWS is not life threatening, but one study found high rates of anxiety (54%-93%) among patients with moderate to severe CWS.^14,15

Few trials have evaluated treatments for chest wall pain or costochondritis, though typical recommendations include nonsteroidal anti-inflammatory medications, use of heat or cold, physical therapy, or injection of local anesthetic.¹⁶ One study found that stretching exercises might benefit patients with costochondritis.¹⁷

GI disorders. Patients with esophagitis or gastroesophageal reflux disease (GERD) often report heartburn, chronic cough, chronic laryngitis, and asthma.¹⁸ However, the sensitivity and specificity of these symptoms are too low to allow diagnosis or exclusion of GERD based on history alone.¹⁸

Chest wall tenderness on palpation largely rules out acute coronary syndrome.Acid suppression therapy can be used to test for GERD. A 2005 meta-analysis of 6 studies found the sensitivity and specificity of a proton-pump inhibitor (PPI) acid suppression test for the diagnosis of GERD in patients with noncardiac chest pain were 80% (95% CI, 71%-87%) and 74% (95% CI, 64%-83%), respectively.¹⁹ One study demonstrated that relief of chest pain after a 14-day course of omeprazole 40 mg/d was more sensitive than endoscopy, manometry, or 24-hour esophageal pH monitoring in diagnosing GERD.²⁰ Another study found that in patients with noncardiac chest pain and normal upper endoscopy, symptomatic relief with lansoprazole 30 mg/d for 4 weeks can be used to diagnose endoscopy-negative GERD.²¹

It is appropriate to try a high-dose course of a PPI (ie, omeprazole 40 mg twice daily, lansoprazole 30 mg/d, or esomeprazole 40 mg twice daily) to evaluate for GERD as the cause of chest pain in patients who:^20-22
• do not initially describe typical reflux symptoms (eg, heartburn, chronic regurgitation, chronic cough, or a sore or burning throat)
• have no history of surgery in the upper GI tract, esophagus, or thorax, and
• have no signs or symptoms that indicate they have a serious or malignant disease (eg, weight loss, anemia, or dysphagia).