Diferencia entre revisiones de «Acute chest pain»
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''See [[Acute coronary syndrome (main)]] for ACS-specific workup and risk stratification; see [[Chest pain (peds)]] for pediatric patients.'' | ''See [[Acute coronary syndrome (main)]] for ACS-specific workup and risk stratification; see [[Chest pain (peds)]] for pediatric patients.'' | ||
==Background== | ==Background== | ||
*Chest pain accounts for approximately 6-8% of all ED visits | *Chest pain accounts for approximately 6-8% of all ED visits<ref>Gulati M, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Nov 30;144(22):e368-e454. PMID 34709879</ref><ref>Kontos MC, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Nov 15;80(20):1925-1960. PMID 36241466</ref> | ||
*The primary ED goal is to rapidly identify and treat '''immediately life-threatening causes''' ("the big 5"): | *The primary ED goal is to rapidly identify and treat '''immediately life-threatening causes''' ("the big 5"): | ||
**[[Acute coronary syndrome]] (ACS) | **[[Acute coronary syndrome]] (ACS) | ||
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==Evaluation== | ==Evaluation== | ||
===Workup=== | ===Workup=== | ||
* | *All patients: | ||
**[[ECG]] - within 10 minutes of arrival; repeat if symptoms change or initially nondiagnostic | **[[ECG]] - within 10 minutes of arrival; repeat if symptoms change or initially nondiagnostic | ||
**[[CXR]] | **[[CXR]] | ||
**Vital signs including bilateral blood pressures if dissection suspected | **Vital signs including bilateral blood pressures if dissection suspected | ||
* | *Moderate-to-high risk or concerning features: | ||
**[[Troponin]] - serial troponins (0h and 1-3h with high-sensitivity assay; 0h and 3-6h with conventional assay) | **[[Troponin]] - serial troponins (0h and 1-3h with high-sensitivity assay; 0h and 3-6h with conventional assay) | ||
**CBC, BMP | **CBC, BMP | ||
**Consider coagulation studies | **Consider coagulation studies | ||
* | *Additional testing based on suspicion: | ||
**[[D-dimer]] or [[CT-PA]] - if PE suspected (use validated pretest probability tools: Wells score, PERC rule, YEARS algorithm) | **[[D-dimer]] or [[CT-PA]] - if PE suspected (use validated pretest probability tools: Wells score, PERC rule, YEARS algorithm) | ||
**[[CT angiography]] of chest/abdomen/pelvis - if [[aortic dissection]] suspected | **[[CT angiography]] of chest/abdomen/pelvis - if [[aortic dissection]] suspected | ||
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===Risk Stratification=== | ===Risk Stratification=== | ||
* | *[[HEART Score]]: Validated tool for risk stratification in undifferentiated chest pain | ||
**Score 0-3: Low risk; consider early discharge | **Score 0-3: Low risk; consider early discharge | ||
**Score 4-6: Moderate risk; admission/observation with serial troponins | **Score 4-6: Moderate risk; admission/observation with serial troponins | ||
**Score 7-10: High risk; admission with cardiology consultation | **Score 7-10: High risk; admission with cardiology consultation | ||
* | *[[Wells score]]: For pretest probability of PE | ||
* | *[[PERC rule]]: If low pretest probability, PERC can exclude PE without D-dimer | ||
==Management== | ==Management== | ||
*Treat based on underlying cause: | *Treat based on underlying cause: | ||
** | **[[ACS]]: ASA, anticoagulation, cardiology consultation; PCI for STEMI (see [[ST-segment elevation myocardial infarction]]) | ||
** | **[[PE]]: Anticoagulation; thrombolytics for massive PE (see [[Pulmonary embolism]]) | ||
** | **[[Aortic dissection]]: HR and BP control; emergent surgical consultation for Type A (see [[Nontraumatic thoracic aortic dissection]]) | ||
** | **[[Tension pneumothorax]]: Needle decompression followed by chest tube | ||
** | **[[Pericardial tamponade]]: Pericardiocentesis | ||
* | *Pain control: Avoid NSAIDs if ACS suspected; nitroglycerin for ischemic pain (avoid in RV infarct, recent PDE5 inhibitor use, hypotension) | ||
==Disposition== | ==Disposition== | ||
* | *Admit to ICU/monitored bed: | ||
**STEMI, unstable ACS, hemodynamically significant PE, aortic dissection, pericardial tamponade | **STEMI, unstable ACS, hemodynamically significant PE, aortic dissection, pericardial tamponade | ||
* | *Admit/observe: | ||
**Moderate HEART score with pending serial troponins | **Moderate HEART score with pending serial troponins | ||
**NSTEMI awaiting cardiology evaluation | **NSTEMI awaiting cardiology evaluation | ||
* | *Discharge: | ||
**Low HEART score (0-3) with negative serial troponins | **Low HEART score (0-3) with negative serial troponins | ||
**Clear non-cardiac cause identified (e.g., musculoskeletal, GERD) | **Clear non-cardiac cause identified (e.g., musculoskeletal, GERD) | ||
Revisión actual - 10:43 22 mar 2026
See Acute coronary syndrome (main) for ACS-specific workup and risk stratification; see Chest pain (peds) for pediatric patients.
Background
- Chest pain accounts for approximately 6-8% of all ED visits[1][2]
- The primary ED goal is to rapidly identify and treat immediately life-threatening causes ("the big 5"):
- Acute coronary syndrome (ACS)
- Pulmonary embolism (PE)
- Aortic dissection
- Tension pneumothorax
- Esophageal perforation (Boerhaave syndrome)
- Most chest pain in the ED is ultimately non-cardiac, but the evaluation is driven by the need to exclude dangerous etiologies
Clinical Features
Risk of Acute Coronary Syndrome
Clinical factors that increase likelihood of ACS/AMI:[3][4]
- Chest pain radiating to both arms > R arm > L arm
- Chest pain associated with diaphoresis
- Chest pain associated with nausea OR vomiting
- Chest pain with exertion that is improved with rest
Clinical factors that decrease likelihood of ACS/AMI:[5]
- Pleuritic chest pain
- Positional chest pain
- Sharp, stabbing chest pain
- Chest pain reproducible with palpation
Gender differences in ACS
- Women with ACS:
- Less likely to be treated with guideline-directed medical therapies[6]
- Less likely to undergo cardiac catheterization[6]
- Less likely to receive timely reperfusion therapy[6]
- More likely to report fatigue, dyspnea, indigestion, nausea or vomiting, palpitations, or weakness,[6] although some studies have found fewer differences in presentation[7]
- More likely to delay presentation[6]
- Men with ACS:
- More likely to report central chest pain
Factors associated with delayed presentation[6]
- Female sex
- Older age
- Black or Hispanic race
- Low educational achievement
- Low socioeconomic status
- Key historical features to assess:
- Quality: crushing/pressure (ACS), tearing/ripping (dissection), pleuritic/sharp (PE, pericarditis, pneumothorax)
- Radiation: jaw/arm (ACS), back (dissection), shoulder (pericarditis)
- Onset: sudden (PE, dissection, pneumothorax) vs gradual (ACS, musculoskeletal)
- Associated symptoms: diaphoresis, dyspnea, nausea/vomiting, syncope
- Risk factors: cardiac history, DVT/PE risk factors, cocaine use, connective tissue disease, recent procedure
- Red flags:
- Hemodynamic instability
- New ECG changes (ST elevation/depression, new LBBB)
- Unequal blood pressures or pulses (aortic dissection)
- Tracheal deviation, absent breath sounds (tension pneumothorax)
- Subcutaneous emphysema (pneumomediastinum, esophageal perforation)
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Evaluation
Workup
- All patients:
- Moderate-to-high risk or concerning features:
- Troponin - serial troponins (0h and 1-3h with high-sensitivity assay; 0h and 3-6h with conventional assay)
- CBC, BMP
- Consider coagulation studies
- Additional testing based on suspicion:
- D-dimer or CT-PA - if PE suspected (use validated pretest probability tools: Wells score, PERC rule, YEARS algorithm)
- CT angiography of chest/abdomen/pelvis - if aortic dissection suspected
- BNP/NT-proBNP - if CHF suspected
- Point-of-care echo - for pericardial effusion, RV strain, wall motion abnormalities, aortic root dilation
Risk Stratification
- HEART Score: Validated tool for risk stratification in undifferentiated chest pain
- Score 0-3: Low risk; consider early discharge
- Score 4-6: Moderate risk; admission/observation with serial troponins
- Score 7-10: High risk; admission with cardiology consultation
- Wells score: For pretest probability of PE
- PERC rule: If low pretest probability, PERC can exclude PE without D-dimer
Management
- Treat based on underlying cause:
- ACS: ASA, anticoagulation, cardiology consultation; PCI for STEMI (see ST-segment elevation myocardial infarction)
- PE: Anticoagulation; thrombolytics for massive PE (see Pulmonary embolism)
- Aortic dissection: HR and BP control; emergent surgical consultation for Type A (see Nontraumatic thoracic aortic dissection)
- Tension pneumothorax: Needle decompression followed by chest tube
- Pericardial tamponade: Pericardiocentesis
- Pain control: Avoid NSAIDs if ACS suspected; nitroglycerin for ischemic pain (avoid in RV infarct, recent PDE5 inhibitor use, hypotension)
Disposition
- Admit to ICU/monitored bed:
- STEMI, unstable ACS, hemodynamically significant PE, aortic dissection, pericardial tamponade
- Admit/observe:
- Moderate HEART score with pending serial troponins
- NSTEMI awaiting cardiology evaluation
- Discharge:
- Low HEART score (0-3) with negative serial troponins
- Clear non-cardiac cause identified (e.g., musculoskeletal, GERD)
- PE ruled out with validated approach
- Arrange appropriate follow-up (PCP within 72 hours for intermediate-risk patients)
Calculators
HEART Score
| Criteria | Select One | ||
|---|---|---|---|
| History | Slightly suspicious (0) | Moderately suspicious (+1) | Highly suspicious (+2) |
| EKG | Normal (0) | Non-specific repolarization disturbance (+1) | Significant ST deviation (+2) |
| Age | <45 (0) | 45–64 (+1) | ≥65 (+2) |
| Risk Factors
HTN, hypercholesterolemia, DM, obesity (BMI >30), smoking, family hx CVD, or hx atherosclerotic disease |
No known risk factors (0) | 1–2 risk factors (+1) | ≥3 risk factors or hx atherosclerotic disease (+2) |
| Initial Troponin | ≤normal limit (0) | 1–3× normal limit (+1) | >3× normal limit (+2) |
| HEART Score | / 10 | ||
| 0–3 | Low Risk — 0.9–1.7% risk of MACE. Consider discharge with outpatient follow-up. |
|---|---|
| 4–6 | Moderate Risk — 12–16.6% risk of MACE. Consider admission for observation and further workup. |
| 7–10 | High Risk — 50–65% risk of MACE. Consider early invasive measures (cardiology consult, catheterization). |
| References |
|---|
|
See Also
- Acute coronary syndrome (main)
- ST-segment elevation myocardial infarction
- Pulmonary embolism
- Nontraumatic thoracic aortic dissection
- Pericarditis
- HEART Score
- Chest pain (peds)
- Cocaine chest pain
References
- ↑ Gulati M, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Nov 30;144(22):e368-e454. PMID 34709879
- ↑ Kontos MC, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Nov 15;80(20):1925-1960. PMID 36241466
- ↑ Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454
- ↑ Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377
- ↑ Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.
- ↑ Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.