Materiały źródłowe

• #1 Chest Pain Differential Diagnosis – The Cardiology Advisor

  https://www.thecardiologyadvisor.com/ddi/chest-pain-differential-diagnosis/

  As a prevalent medical complaint, chest pain differential diagnosis often is needed. There are numerous causes of chest pain, some of them life-threatening, and it accounts for 5% of all emergency hospital visits. It is most commonly caused by acute coronary syndrome, but chest pain also can be caused by factors including: gastrointestinal reflux disease (the most common non-cardiac cause of chest pain), pulmonary embolisms, pericarditis, and musculoskeletal factors. […] When a patient presents to a health care facility with chest pain, this chest pain should be triaged with a high priority level. An ECG should be administered to patients with suspected cardiac etiology of their chest pain, and the ECG results used to determine the necessary care plan. […] If a patient presents with chest pain, it can often be difficult for them to describe it or identify its precise point of origin. This creates a challenge for medical professionals in chest pain diagnosis.

• #1 Chest pain – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/chest-pain/diagnosis-treatment/drc-20370842

  Chest pain doesn’t always mean that you’re having a heart attack. But that’s what emergency medical help usually tests for first because it can be life-threatening. Your healthcare professionals also will check for life-threatening lung conditions such as a collapsed lung or a blood clot in the lung. […] Some of the first tests done to diagnose the cause of chest pain are: […] Electrocardiogram (ECG or EKG). This quick test shows how the heart is beating. The test can tell if you have had or are having a heart attack. […] Blood tests. Certain heart proteins and other substances slowly leak into the blood after heart damage from a heart attack. Blood tests can be done to check for these. […] Chest X-ray. An X-ray of the chest shows the condition of the lungs and the size and shape of the heart. A chest X-ray can diagnose pneumonia or a collapsed lung.

• #1 Chest pain – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/chest-pain/diagnosis-treatment/drc-20370842

  Computerized tomography (CT) scan. A CT scan uses X-rays to create cross-sectional images of specific parts of the body. A CT scan of the chest can spot a blood clot in the lung or find an aortic dissection. […] Depending on the results from the first tests for chest pain, you may need more testing, which may include: […] Echocardiogram. Sound waves create images of the beating heart. This test shows how blood moves through the heart and heart valves. […] CT coronary angiogram. This test looks at the arteries that supply blood to the heart. It uses a powerful X-ray machine to make images of the heart and its blood vessels. The test is used to diagnose many different heart conditions. […] Exercise stress test. For this test, you walk on a treadmill or ride a stationary bike while a healthcare professional watches the heartbeat. Exercise tests help show how the heart reacts to exercise. If you can’t exercise, you might get medicines that affect the heart like exercise does.

• #1 Chest pain – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/chest-pain/diagnosis-treatment/drc-20370842

  Coronary catheterization. This test can find blockages in the heart arteries. A long, thin flexible tube is inserted into a blood vessel, usually in the groin or wrist, and guided to the heart. Dye flows through the tube to arteries in the heart. The dye helps the arteries show up more clearly on X-ray images and video. […] Once you’re at the hospital for chest pain, you’re usually examined quickly. Based on results from blood tests and a heart monitor, your healthcare professional can quickly know if you are having a heart attack or not. […] A healthcare professional who sees you for chest pain may ask: […] What’s the most likely cause of my chest pain? […] Are there other possible causes for my symptoms or condition? […] What kinds of tests do I need? […] Do I need to stay in the hospital?

• #1 Chest Pain Diagnosis

  https://www.uvmhealth.org/medcenter/conditions-and-treatments/chest-pain/chest-pain-diagnosis

  Magnetic resonance imaging (MRI): An MRI uses magnetic fields and radio waves to produce cross-sectional images of your body. The specialists at The UVM Medical Center are experts at imaging the heart with MRI. They look for abnormalities in heart structure and function, and they can measure scar after a heart attack. […] Echocardiogram: This is an ultrasound of the heart, using no radiation. It is a safe and non-invasive way to look at the heart’s pumping function and at the heart valves. Echocardiography uses sound waves to create a live video image of your heart. […] Endoscopy: With this test, a scope with a tiny camera on the end is inserted into your throat, allowing doctors to see your esophagus and stomach. Endoscopy can be used to identify any gastro-esophageal problems that may be related to your chest pain.

• #1 Chest Pain Diagnosis

  https://www.uvmhealth.org/medcenter/conditions-and-treatments/chest-pain/chest-pain-diagnosis

  Chest X-ray: An x-ray can be useful in showing condition of your lungs, as well as the size and shape of your heart and major blood vessels. These images will allow our chest x-ray specialists to identify any damage. […] Nuclear scan: Nuclear medicine experts at The UVM Medical Center inject trace amounts of radioactive material into your bloodstream. This material is concentrated in the heart muscle and is visible on special cameras, allowing doctors to identify heart muscle starved of blood flow due to a blockage. […] Coronary catheterization or angiogram: Experts in The UVM Medical Center’s Cardiac Catheterization Laboratory inject a dye into the arteries of your heart through a catheter. The dye is visible on x-ray and video, helping to identify any blocked or narrowed arteries. […] Computed Tomography (CT) scan: The UVM Medical Center’s Emergency Department features a highly advanced CT scanner. This advanced technology provides comprehensive images of organs within seconds with a high degree of accuracy. The latest-generation specialized CT scanners available at The UVM Medical Center allow specialists to see if your heart’s coronary arteries have significant plaque buildup that leads to blockages.

• #1 Chest Pain: Causes, Diagnosis, and Treatment

  https://www.healthline.com/health/chest-pain

  When you have chest pain, your first thought may be that its a heart attack. […] Chest pain is one of the most common reasons that people visit the emergency room (ER). […] According to one study, only 5.5 percent of all ER visits for chest pain result in a diagnosis of a serious heart-related problem. […] Seek emergency treatment immediately if you think you may be having a heart attack and especially if your chest pain is new, unexplained, or lasts more than a few moments. […] Your doctor will ask you some questions, and your answers can help them diagnose the cause of your chest pain. […] Your doctor may order tests to help diagnose or eliminate heart-related problems as a cause of your chest pain. […] If you need help finding a primary care doctor, you can browse doctors in your area through the Healthline FindCare tool.

• #1 Chest Pain Differential Diagnosis – The Cardiology Advisor

  https://www.thecardiologyadvisor.com/ddi/chest-pain-differential-diagnosis/

  The evaluation of the patient with chest pain should begin with a full physical examination. […] When the patient presents with chest pain symptoms, it’s important to rule out life-threatening conditions like acute coronary syndrome. […] Once it’s determined the chest pain is not cardiac in origin, pleuritic or chest wall pain may also be considered. […] When diagnosing chest pain, there are many effective tools. When determining the causes of chest pain, one effective tool is HEART, a chest pain differential diagnosis mnemonic. […] Each factor above corresponds to a numeric ranking, which is then added up and used to group patients into low, moderate, or high risk of life-threatening cardiac emergencies. […] Once a thorough examination has been performed, medical professionals should be able to accurately diagnose the causes of chest pain and recommend the appropriate treatment. If, after examination, the exact cause of chest pain still can not be identified, the patient should be referred to a specialist for further testing.

• #1 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP

  https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html

  Approximately 1% of primary care office visits are for chest pain, and 2% to 4% of these patients will have unstable angina or myocardial infarction. […] Initial evaluation is based on determining whether the patient needs to be referred to a higher level of care to rule out acute coronary syndrome (ACS). […] A combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease as the cause of chest pain. […] The Marburg Heart Score and the INTERCHEST clinical decision rule can also help estimate ACS risk. […] Twelve-lead electrocardiography is recommended to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions. […] Patients with suspicion of ACS or changes on electrocardiography should be transported immediately to the emergency department.

• #1 Diagnosing the Cause of Chest Pain | AAFP

  https://www.aafp.org/pubs/afp/issues/2005/1115/p2012.html

  The Rouan decision rule reliably predicts which patients with chest pain and a normal or nonspecific electrocardiogram (ECG) are at higher risk for MI. […] However, because up to 3 percent of patients initially diagnosed with a noncardiac cause of chest pain suffer death or MI within 30 days of presentation, patients with cardiac risk factors such as male sex, greater age, diabetes, hyperlipidemia, prior CAD, or heart failure warrant close follow-up. […] d-dimer testing has become an important part of the evaluation for PE and deep venous thrombosis (DVT). […] A low clinical suspicion for PE (e.g., Wells score less than 2) plus a normal quantitative ELISA d-dimer assay safely rules out PE, with a negative predictive value greater than 99.5 percent. […] Chest radiograph generally is considered the reference standard for patients suspected of having pneumonia, and it is the standard against which clinical evaluations for pneumonia are compared.

• #1 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP

  https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html

  A meta-analysis of studies that evaluated the role of previous chest pain in diagnosing ACS concluded that chest pain that is pleuritic, positional, or reproducible with palpation and not related to exertion is low risk for ACS. […] Pain that is described as pressure (similar to that of prior myocardial infarction), worse than prior anginal pain, associated with exertion, accompanied by nausea or diaphoresis, and/or radiates to one or both arms/shoulders is higher risk for ACS. […] The combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease (CAD) as the cause of chest pain. […] Validated clinical decision rules can help determine whether chest pain is caused by CAD. […] One systematic review found that the validated Marburg Heart Score is better than clinical judgment alone for predicting whether chest pain is cardiac in origin.

• #1 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP

  https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html

  The INTERCHEST clinical decision rule is a second validated decision rule that can predict the presence or absence of CAD in patients who present with chest pain in the primary care setting. […] Because history alone usually cannot determine whether a patient is actively experiencing cardiac ischemia, a 12-lead ECG should be performed on all patients in whom cardiac ischemia is suspected. […] ECG findings that increase the likelihood of ACS include ST segment elevation, new-onset left bundle branch block, presence of Q waves, or new T-wave inversions. […] Patients with suspicion of ACS based on clinical presentation (history, physical examination, risk factors) with changes seen on ECG should be transported immediately to the emergency department. […] For patients with chest pain not requiring immediate referral who have a low to intermediate pretest probability of CAD, exercise stress testing should be considered.

• #1 Noncardiac Chest Pain: Symptoms, Causes and Treatments

  https://my.clevelandclinic.org/health/diseases/15851-gerd-non-cardiac-chest-pain

  If you experience chest pain that resembles cardiac chest pain, you should go to the emergency room. On arrival, youll receive a complete physical exam that measures all of your vital signs, including blood pressure and heart rate. Then youll be screened for heart attack or heart disease. Tests include an electrocardiogram (EKG) a noninvasive test that records your hearts electrical activity and blood tests. Your heart releases certain proteins when a heart attack occurs that will show up in a blood test. Only when cardiac factors have been ruled out will you be diagnosed with noncardiac chest pain. […] Once a cardiologist or your primary care provider has ruled out cardiac causes, youll likely be referred to a gastroenterologist next. Theyll test you for esophagus-based causes, starting with GERD. One way of testing is to send you home with a proton-pump inhibitor (PPI), a highly effective medicine for GERD. If the PPI relieves your symptoms, it can also confirm their cause. Other tests may include a PH study of the esophagus, an esophageal motility test, an upper endoscopy or ultrasound.

• #1 Diagnosis and Management of Noncardiac Chest Pain – Gastroenterology & Hepatology

  https://www.gastroenterologyandhepatology.net/archives/september-2024/diagnosis-and-management-of-noncardiac-chest-pain/

  Psychiatric comorbidities, including depression, anxiety, and panic disorder, are present in at least half of patients with NCCP and are associated with decreased quality of life. […] GERD is the most common cause of NCCP, occurring in 30% to 60% of patients and predictive of response to a proton pump inhibitor (PPI). […] Given the high prevalence of GERD, this should be the first condition considered in patients with NCCP. […] If alarm signs or symptoms are present, such as unintentional weight loss, dysphagia, unexplained iron deficiency anemia, family history of gastrointestinal malignancy, or gastrointestinal bleeding, initial evaluation of NCCP should include upper endoscopy. […] For patients who do not respond to a therapeutic trial of a PPI, further evaluation of the upper gastrointestinal tract is typically recommended with upper endoscopy and/or ambulatory pH monitoring.

• #1 Diagnosis and Management of Noncardiac Chest Pain – Gastroenterology & Hepatology

  https://www.gastroenterologyandhepatology.net/archives/september-2024/diagnosis-and-management-of-noncardiac-chest-pain/

  Esophageal dysmotility is the least common esophageal cause of NCCP and is typically evaluated by high-resolution esophageal manometry (HRM) once other secondary causes such as GERD have been ruled out. […] Functional gastrointestinal disorders, now referred to as DGBIs, are defined as a group of disorders characterized by gastrointestinal symptoms in the absence of obvious structural abnormalities. […] Functional chest pain accounts for approximately one-third of patients diagnosed with esophageal-related NCCP and is the second most common cause of NCCP after GERD. […] As visceral hypersensitivity is proposed as the underlying mechanism of functional chest pain, neuromodulators targeting pain processing are the mainstay of treatment, including serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, selective serotonin reuptake inhibitors, theophylline, gabapentin, pregabalin, and trazodone. […] NCCP is a common disorder that greatly impacts quality of life and is associated with a high health care burden and comorbid psychiatric disease.

• #1 Diagnosis and treatment of musculoskeletal chest pain: design of a multi-purpose trial | BMC Musculoskeletal Disorders | Full Text

  https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-9-40

  Furthermore knowledge about the benefits of manual treatment of patients with musculoskeletal chest pain will inform clinical decision and policy development in relation to clinical practice. […] Chest pain differential diagnoses include primarily pulmonary, gastrointestinal, psychosocial, or musculoskeletal problems. Musculoskeletal problems alone accounts for 520% of the total number of admissions in acute chest pain clinics. […] Hence, the musculoskeletal system is a recognized possible source of pain in patients with chest pain, even if no standardized criteria for the diagnosis exist at this point. […] An extensive body of literature addresses patient assessment and management protocols for patients presenting with chest pain, but these focus primarily on cardiopulmonary, gastro-oesophageal, and psychological conditions, and protocols aiming at diagnosis of musculoskeletal chest pain remain scarce, and the effect of treatment strategies, including medical treatment (oral anti-inflammatory drugs), exercise (strength and/or stretching), advice, and manual approaches have not been evaluated.

• #1 Chest pain – Wikipedia

  https://en.wikipedia.org/wiki/Chest_pain

  In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax, and cardiac tamponade. By elimination or confirmation of the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided. […] If acute coronary syndrome („heart attack”) is suspected, many people are admitted briefly for observation, sequential ECGs, and measurement of cardiac enzymes in the blood over time. On occasion, further tests on follow up may determine the cause.

• #1 ACC/CHEST/AHA/ASECHO/SCCT Evaluation and Diagnosis of Chest Pain Guideline Pocket Guide

  https://www.guidelinecentral.com/guideline/450303/pocket-guide/450307/

  In patients presenting with acute chest pain, serial cTn I or T levels are useful to identify abnormal values and a rising or falling pattern indicative of acute myocardial injury. […] In patients presenting with acute chest pain, high-sensitivity cTn is the preferred biomarker because it enables more rapid detection or exclusion of myocardial injury and increases diagnostic accuracy. […] In patients with acute chest pain and suspected ACS, clinical decision pathways (CDPs) should categorize patients into low-, intermediate-, and high-risk strata to facilitate disposition and subsequent diagnostic evaluation. […] In the evaluation of patients presenting with acute chest pain and suspected ACS for whom serial troponins are indicated to exclude myocardial injury, recommended time intervals after the initial troponin sample collection for repeat measurements are: 1 to 3 hours for high-sensitivity troponin and 3 to 6 hours for conventional troponin assays.

• #1 Diagnosing the Cause of Chest Pain | AAFP

  https://www.aafp.org/pubs/afp/issues/2005/1115/p2012.html

  Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. […] In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. […] Risk of pulmonary embolism can be determined with a simple prediction rule, and a d-dimer assay can help determine whether further evaluation with helical computed tomography or venous ultrasound is needed. […] Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis.

• #1 Cardiac-type Chest Pain Presenting in Primary Care

  https://patient.info/doctor/cardiac-type-chest-pain-presenting-in-primary-care

  The assessment of any patient with possible cardiac chest pain should include smoking history, past history of cardiovascular disease and comorbidities, especially diabetes, hypertension and hyperlipidaemia. […] Investigations may be required to exclude non-cardiac causes of chest pain – eg, CXR (pneumonia), abdominal ultrasound (gallstones), serum amylase (acute pancreatitis). Initial blood investigations include cardiac enzymes, fasting lipids, fasting glucose and FBC (to exclude anaemia, and high white cell count may suggest pneumonia). […] For those patients not requiring immediate hospital admission, chest pain clinics enable rapid confirmation of the diagnosis, initiation of treatment, and, where considered appropriate, further investigation and intervention.

• #1

  https://www.nursingcenter.com/clinical-resources/guideline-summaries/chest-pain

  Pay close attention to accompanying symptoms that are more common in women with acute coronary syndrome (ACS): nausea, fatigue, shortness of breath. […] Consider ACS when accompanying symptoms such as shortness of breath, syncope, or acute delirium are present, or when an unexplained fall occurs. […] Educate all patients and bystanders to call 911 to initiate transport to the closest emergency department (ED) by emergency medical services (EMS) when acute chest pain occurs. […] Perform a focused cardiovascular examination. Identify life-threatening causes of chest pain. […] Measure high-sensitivity cardiac troponin (cTn) as soon as possible on any patient presenting to ED with acute chest pain and suspected ACS. […] If initial ECG is nondiagnostic, perform serial ECGs when clinical suspicion for ACS is high, symptoms persist, or clinical condition deteriorates.

• #1

  https://www.nhs.uk/conditions/heart-attack/diagnosis/

  If a heart attack is suspected, you should be admitted to hospital immediately. You will usually be admitted to an acute cardiac care unit (ACCU), or directly to the cardiac catheterisation unit, to confirm the diagnosis and begin treatment. […] An electrocardiogram (ECG) is an important test in suspected heart attacks. It should be done within 10 minutes of being admitted to hospital. […] An ECG is important because: it helps confirm the diagnosis of a heart attack; it helps determine what type of heart attack you have had, which will help determine the most effective treatment. […] If doctors suspect you have had a heart attack, a sample of your blood will be taken so it can be tested for these heart proteins (known as cardiac markers). […] The most common protein measurement is called cardiac troponin. Your troponin level can help in diagnosing the type of heart attack you’ve had.

• #1 First-Ever Guideline Focused Solely on Chest Pain Evaluation, Diagnosis Released

  https://www.acc.org/Latest-in-Cardiology/Articles/2021/10/27/13/05/First-Ever-Guideline-Focused-Solely-on-Chest-Pain-Evaluation-Diagnosis-Released-gl_chestpain

  As such, they highlight the need for further research and new approaches for reducing delays from chest pain symptom onset to presentation, as well as the need for continued research and best practices for reducing the differences in both sex, gender and racial differences in treatment and outcomes. […] Additionally, they point out the important role that registries will play as platforms within which to conduct randomized trials and note the need to evaluate the impact of accreditation activities coupled with registry participation on clinical outcomes and process improvement.

• #1 First-Ever Guideline Focused Solely on Chest Pain Evaluation, Diagnosis Released

  https://www.acc.org/Latest-in-Cardiology/Articles/2021/10/27/13/05/First-Ever-Guideline-Focused-Solely-on-Chest-Pain-Evaluation-Diagnosis-Released-gl_chestpain

  All imaging modalities highlighted in the guideline have an important role in the assessment of chest pain to help determine the underlying cause, with the goal of preventing a serious cardiac event. […] Also of note, the use of „noncardiac” as a descriptor of chest pain is encouraged in place of „atypical,” which the authors say is misleading. […] Other recommendations include leveraging routine use of clinical decision pathways for chest pain in the emergency department and outpatient settings, as well as the use of structured risk assessment using evidence-based protocols for patients presenting with acute or stable chest pain, or in those patients at risk for coronary artery disease or adverse events. […] Looking ahead, the authors recognize that „the diagnosis and management of chest pain will remain a fertile area of investigation.”

• #1 Chest Pain Diagnosis – Health Innovation Manchester

  https://healthinnovationmanchester.com/our-work/chest-pain-diagnosis/

  Chest pain is one of the most common reasons for 999 calls for an ambulance, averaging approximately 2,000 daily cases in England. […] Currently it can be difficult for paramedics to accurately determine whether a patient suffering from chest pain is having a heart attack. The Chest Pain Diagnosis project aims to improve care for patients receiving an emergency ambulance response for acute chest pain by providing paramedics with access to a point-of-care test for a biomarker called Troponin that is released when a patient is having a heart attack. The results of this test (and other clinical observations) will be input by paramedics into a computerised decision aid called T-MACS which calculates the probability that an individuals symptoms are caused by a heart attack. This innovative way of working will enable paramedics to accurately identify patients that are suffering from a heart attack, allowing them to receive earlier, more personalised treatment when they arrive in hospital.

• #1 Chest pain

  https://www1.racgp.org.au/ajgp/2024/july/chest-pain

  In conclusion, chest pain is a common symptom that can range from benign to life-threatening causes, making it a challenging presentation for healthcare providers. […] When evaluating patients with chest pain, it is essential to differentiate between serious and benign causes of discomfort, and it is crucial to identify potentially life-threatening causes and evaluate the need for emergency care before considering other common causes of chest pain.

• #1 Chest Pain – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/symptoms-of-cardiovascular-disorders/chest-pain

  Chest pain is a very common presenting symptom. Many patients are well aware that it is a warning of potential life-threatening disorders and seek evaluation for minimal symptoms. Other patients, including many with serious disease, minimize or ignore its warnings. […] However described, chest pain should never be dismissed without an explanation of its cause. […] Most patients with chest pain should have pulse oximetry, ECG, and chest radiography (basic tests). If there is suspicion of coronary ischemia, serum cardiac biomarkers (troponin, CK-MB) should also be checked. […] Red flag findings include abnormal vital signs (tachycardia, bradycardia, tachypnea, hypotension), signs of hypoperfusion (eg, confusion, ashen color, diaphoresis), shortness of breath, asymmetric breath sounds or pulses, new heart murmurs, or pulsus paradoxus 10 mm Hg.

• #1

  https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-approach-to/chest-pain

  It is important to note that even a normal ECG does not rule out acute coronary syndrome, and a large percentage of patients with acute coronary syndrome have a normal ECG. […] Serial biomarker Troponin I and Troponin T are critical to assess for ACS. […] Clinical Decision Rules can be used as cognitive checks and to risk stratify cases of chest pain. […] Clinical decision rules are very helpful in the management of suspected acute coronary syndrome because history and physical exam is often not sensitive enough. […] Encapsulating all the possibilities therapies for chest pain can be difficult. […] A way to think about treat is to beak it into initial ED management and definitive treatment. […] If the EKG is not diagnostic, a secondary survey focused on the key features of life-threatening chest pain will be needed. […] Do not rely on a normal EKG and a normal Troponin to rule out acute coronary syndrome, they are not sensitive enough! Clinical decision rules can be helpful to guide disposition.

• #2 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP

  https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html

  Approximately 1% of primary care office visits are for chest pain, and 2% to 4% of these patients will have unstable angina or myocardial infarction. […] Initial evaluation is based on determining whether the patient needs to be referred to a higher level of care to rule out acute coronary syndrome (ACS). […] A combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease as the cause of chest pain. […] The Marburg Heart Score and the INTERCHEST clinical decision rule can also help estimate ACS risk. […] Twelve-lead electrocardiography is recommended to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions. […] Patients with suspicion of ACS or changes on electrocardiography should be transported immediately to the emergency department.

• #2 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP

  https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html

  Those at low or intermediate risk of ACS can undergo exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging. […] In those with low suspicion for ACS, consider other diagnoses such as chest wall pain or costochondritis, gastroesophageal reflux disease, and panic disorder or anxiety states. […] Other less common, but important, diagnostic considerations include acute pericarditis, pneumonia, heart failure, pulmonary embolism, and acute thoracic aortic dissection. […] The first decision point for most physicians is to determine whether the patient needs immediate referral to the emergency department for further testing to determine whether the chest pain is an acute coronary syndrome (ACS) caused by coronary ischemia. […] The impression of chest pain is often determined by a combination of clinical symptoms at the time of presentation, physical examination, initial electrocardiography (ECG), and risk factors for ACS.

• #2 Angina (Chest Pain) – Diagnosis | NHLBI, NIH

  https://www.nhlbi.nih.gov/health/angina/diagnosis

  Your healthcare provider may diagnose angina based on your medical history, a physical exam, and diagnostic tests and procedures. Tests can rule out other conditions and help determine whether you need medical attention right away. […] Your healthcare provider will want to learn about your symptoms and risk factors, such as your personal and family health history, to determine whether your chest discomfort is due to angina or other causes. […] Depending on your symptoms and risk factors, your healthcare provider may want to run some tests to check for medical emergencies. […] An electrocardiogram (ECG) can help recognize types of angina and other serious heart problems. […] A chest X-ray is useful in screening for lung disorders and other causes of chest pain, such as pneumonia and heart failure.

• #2 Chest Pain Diagnosis

  https://www.uvmhealth.org/medcenter/conditions-and-treatments/chest-pain/chest-pain-diagnosis

  Chest X-ray: An x-ray can be useful in showing condition of your lungs, as well as the size and shape of your heart and major blood vessels. These images will allow our chest x-ray specialists to identify any damage. […] Nuclear scan: Nuclear medicine experts at The UVM Medical Center inject trace amounts of radioactive material into your bloodstream. This material is concentrated in the heart muscle and is visible on special cameras, allowing doctors to identify heart muscle starved of blood flow due to a blockage. […] Coronary catheterization or angiogram: Experts in The UVM Medical Center’s Cardiac Catheterization Laboratory inject a dye into the arteries of your heart through a catheter. The dye is visible on x-ray and video, helping to identify any blocked or narrowed arteries. […] Computed Tomography (CT) scan: The UVM Medical Center’s Emergency Department features a highly advanced CT scanner. This advanced technology provides comprehensive images of organs within seconds with a high degree of accuracy. The latest-generation specialized CT scanners available at The UVM Medical Center allow specialists to see if your heart’s coronary arteries have significant plaque buildup that leads to blockages.

• #2 Angina Pectoris – Diagnosis, Evaluation and Treatment

  https://www.radiologyinfo.org/en/info/anginapectoris

  Coronary computed tomography (CT) angiography: This exam evaluates the coronary arteries (blood vessels that supply blood and oxygen to the heart) to determine the extent of narrowing of the arteries due to plaque without the need for an invasive catheter feed through the arteries into the heart. […] Echocardiogram: During this test, a transducer that produces high-frequency sound waves is used to create moving images of the heart. […] Many doctors may recommend certain lifestyle changes such as maintaining a healthy weight, consuming a balanced diet low in fats, discontinuing the use of tobacco products and finding ways to reduce stress. […] Additionally, you may also be treated with: Medications such as aspirin, statins, beta-blockers, calcium channel blockers, or nitrates, as well as newer lipid-lower agents such as PCSK9 inhibitors.

• #2 Chest Pain Diagnosis

  https://www.uvmhealth.org/medcenter/conditions-and-treatments/chest-pain/chest-pain-diagnosis

  Magnetic resonance imaging (MRI): An MRI uses magnetic fields and radio waves to produce cross-sectional images of your body. The specialists at The UVM Medical Center are experts at imaging the heart with MRI. They look for abnormalities in heart structure and function, and they can measure scar after a heart attack. […] Echocardiogram: This is an ultrasound of the heart, using no radiation. It is a safe and non-invasive way to look at the heart’s pumping function and at the heart valves. Echocardiography uses sound waves to create a live video image of your heart. […] Endoscopy: With this test, a scope with a tiny camera on the end is inserted into your throat, allowing doctors to see your esophagus and stomach. Endoscopy can be used to identify any gastro-esophageal problems that may be related to your chest pain.

• #2 Angina (Chest Pain): Diagnosis & Treatment | NewYork-Presbyterian

  https://www.nyp.org/heart/acute-coronary-syndrome/angina/treatment

  Stress tests – Angina can be brought about by exercise. Doctors may have patients walk a treadmill or ride a stationary bicycle while monitoring their heart activity. If a patient cannot exercise, medications are available that can imitate the bodys response to exercise. […] Echocardiogram – This imaging test uses ultrasound waves to create detailed images of the heart and surrounding organs. These images can determine if blood is flowing properly to the heart. […] Nuclear stress test – A dye called a radioactive tracer is injected into a persons bloodstream before beginning a stress test. A special monitor shows how the tracer flows through the arteries. Areas with little or no visible tracer at stress indicate poor blood flow. […] Coronary angiography – This procedure, also called a coronary angiogram, is part of a group of catheterizations. X-rays produce images of the hearts blood vessels, and if a blockage is identified, it can potentially be fixed with a stent, if appropriate, at the same time.

• #2 ACC/CHEST/AHA/ASECHO/SCCT Evaluation and Diagnosis of Chest Pain Guideline Pocket Guide

  https://www.guidelinecentral.com/guideline/450303/pocket-guide/450307/

  In patients with acute chest pain and myocardial injury who have nonobstructive coronary arteries on anatomic testing, CMR with gadolinium contrast is effective to distinguish myopericarditis from other causes. […] In patients with acute chest pain with suspected acute myopericarditis, CMR is useful if there is diagnostic uncertainty, or to determine the presence and extent of myocardial and pericardial inflammation and fibrosis. […] In patients with acute chest pain with suspected acute pericarditis, non-contrast or contrast cardiac CT scanning may be reasonable to determine the presence and degree of pericardial thickening. […] Patients with acute chest pain should be evaluated for noncardiac causes if they have persistent or recurring symptoms despite a negative stress test or anatomic cardiac evaluation, or a low-risk designation by a CDP.

• #2 Evaluation of chest pain – Differential diagnosis of symptoms | BMJ Best Practice US

  https://bestpractice.bmj.com/topics/en-us/301

  Chest pain is a common chief complaint, accounting for approximately 5.6% of all emergency department visits in the US per year. […] It is the presenting complaint in approximately 0.5% of office-based visits. […] Chest pain may be caused by either benign or life-threatening etiologies, and is usually divided into cardiac and noncardiac causes. […] Acute coronary syndrome (ACS; encompassing unstable angina, ST-elevation myocardial infarction, and non-ST-elevation myocardial infarction) may not be the most common etiology in patients presenting with chest pain. Excluding ACS is, however, vital because of the mortality associated with untreated myocardial infarction. […] This topic concentrates on the evaluation of acute chest pain in the emergency setting.

• #2 Acute chest pain – WikEM

  https://wikem.org/wiki/Acute_chest_pain

  Clinical factors that increase likelihood of ACS/AMI: Chest pain radiating to both arms R arm L arm. Chest pain associated with diaphoresis. Chest pain associated with nausea/vomiting. Chest pain with exertion. […] Clinical factors that decrease likelihood of ACS/AMI: Pleuritic chest pain. Positional chest pain. Sharp, stabbing chest pain. Chest pain reproducible with palpation. […] Diagnosis: Consider differential diagnosis (see above) and rule out emergent causes. ACS: Consider using HEART Pathway. PE: See Pulmonary embolism by pretest probability.

• #2 Noncardiac Chest Pain: Symptoms, Causes and Treatments

  https://my.clevelandclinic.org/health/diseases/15851-gerd-non-cardiac-chest-pain

  Noncardiac chest pain is chronic chest pain that feels like its in the heart, but it isnt. Its actually usually in the esophagus, which runs right alongside the heart. If you have persistent episodes of noncardiac chest pain, and your healthcare providers have ruled out cardiac causes, you may be diagnosed with noncardiac chest pain. […] Noncardiac chest pain is defined as recurring pain in your chest typically, behind your breast bone and near your heart thats not related to your heart. In most people, noncardiac chest pain is actually related to a problem with their esophagus, most often gastroesophageal reflux disease (GERD). […] Noncardiac chest pain affects up to 25% of adults in the U.S. Between 50% and 75% of chest pain cases presenting to emergency rooms are discharged without a cardiac diagnosis. These cases are classified either as unexplained, as stress- or anxiety-induced or as NCCP.

• #2 Noncardiac Chest Pain: Symptoms, Causes and Treatments

  https://my.clevelandclinic.org/health/diseases/15851-gerd-non-cardiac-chest-pain

  If you experience chest pain that resembles cardiac chest pain, you should go to the emergency room. On arrival, youll receive a complete physical exam that measures all of your vital signs, including blood pressure and heart rate. Then youll be screened for heart attack or heart disease. Tests include an electrocardiogram (EKG) a noninvasive test that records your hearts electrical activity and blood tests. Your heart releases certain proteins when a heart attack occurs that will show up in a blood test. Only when cardiac factors have been ruled out will you be diagnosed with noncardiac chest pain. […] Once a cardiologist or your primary care provider has ruled out cardiac causes, youll likely be referred to a gastroenterologist next. Theyll test you for esophagus-based causes, starting with GERD. One way of testing is to send you home with a proton-pump inhibitor (PPI), a highly effective medicine for GERD. If the PPI relieves your symptoms, it can also confirm their cause. Other tests may include a PH study of the esophagus, an esophageal motility test, an upper endoscopy or ultrasound.

• #2

  https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-approach-to/chest-pain

  Assessment of all high-risk patients with chest pain should always begin with getting an initial impression then assessing the airway, breathing and circulation paired with vital signs. […] Chest pain is a team sport. […] Should you have a patient who presents with or develops acute distress or cardiac arrest, your diagnosis and treatment need to occur simultaneously with resuscitating the patient. […] Evaluating chest pain is not simple. […] Serial ECGs, serial biomarkers, clinical assessment, imaging and observation may all still be needed to further differentiate many patients. […] Key features are used in a focused history and physical to rapidly differentiate these critical illnesses. […] High risk patients with undifferentiated chest pain should receive an ECG within 5-10 minutes of arriving to the emergency department.

• #2 The assessment and management of chest pain in primary care: A focus on acute coronary syndrome

  https://www1.racgp.org.au/ajgp/2018/may/chest-pain-in-primary-care

  An ECG should be performed within 10 minutes of assessing a patient with suspected ACS for identification of ST-elevation myocardial infarction (STEMI). […] Patients with suspected ACS, including new-onset angina, should be referred urgently to the nearest emergency department. […] The National Heart Foundation and Cardiac Society of Australia and New Zealand 2016 risk classification for suspected cardiac causes of chest pain classifies patients as high, intermediate or low risk. […] As a single troponin test is not able to rule out AMI in patients presenting acutely with suspected ACS, serial testing is performed. […] Individual health services should use a protocol for the risk stratification and subsequent assessment of patients with suspected ACS. […] ACS is common and life-threatening, and must be considered in all patients with chest pain who present to general practice.

• #2 Chest Pain Diagnosis

  https://www.uvmhealth.org/medcenter/conditions-and-treatments/chest-pain/chest-pain-diagnosis

  Highly specialized care by chest pain diagnosis and treatment experts at The UVM Medical Center in Burlington, VT. […] Chest pain has many causes, some of which are life threatening, such as a heart attack. Seek professional medical help immediately and get the care and expertise of a specialized group of physicians who work together as a team to provide advanced care. […] Time is of the essence in diagnosing chest pain, and the evaluation may begin even before you arrive at the hospital. Local ambulances en route to The UVM Medical Center are outfitted with mobile electrocardiograms (ECG). This gives emergency medical service crews important information to share with the Emergency Department, giving cardiac specialists a head start in preparing your treatment. This is why the ambulance is the best way to get to the hospital when you have a chest pain emergency.

• #2 Evaluation & Diagnosis of Chest Pain | stemiecg

  https://www.stemiecg.com/evaluation-diagnosis-of-chest-pain

  (10) STRUCTURED RISK ASSESSMENT SHOULD BE USED […] Clinically For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols. […] This Chest Pain Guideline was developed for the evaluation of acute or stable chest pain in outpatient and emergency department settings, emphasizing the diagnosis of chest pain with an ischemic etiology. […] Acute chest pain refers to symptoms of new onset or change from previous in pattern, intensity, or duration; stable chest pain refers to symptoms that are chronic and associated with consistent precipitants. […] Chest pain is the most common symptom among both men and women diagnosed with acute coronary syndrome (ACS). However, women more commonly have accompanying symptoms including nausea, palpitations, and shortness of breath.

• #2 ACC/CHEST/AHA/ASECHO/SCCT Evaluation and Diagnosis of Chest Pain Guideline Pocket Guide

  https://www.guidelinecentral.com/guideline/450303/pocket-guide/450307/

  Noncardiac should be used if heart disease is not suspected. […] For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols. […] An initial assessment of chest pain is recommended to triage patients effectively on the basis of the likelihood that symptoms may be attributable to myocardial ischemia. […] Chest pain should not be described as atypical, because it is not helpful in determining the cause and can be misinterpreted as benign in nature. […] In patients with chest pain, a focused history that includes characteristics and duration of symptoms relative to presentation as well as associated features, and cardiovascular risk factor assessment should be obtained. […] In patients with chest pain who are 75 years of age, ACS should be considered when accompanying symptoms such as shortness of breath, syncope, or acute delirium are present, or when an unexplained fall has occurred.

• #2 Diagnosing the Cause of Chest Pain | AAFP

  https://www.aafp.org/pubs/afp/issues/2005/1115/p2012.html

  Chest pain is the chief complaint in about 1 to 2 percent of out-patient visits, and although the cause is often noncardiac, heart disease remains the leading cause of death in the United States. […] Thus, distinguishing between serious and benign causes of chest pain is imperative, and diagnostic and prognostic questions are important in making this determination. […] Patients presenting with chest pain should have an ECG evaluation for ST segment elevation, Q waves, and conduction defects. Results should be compared with previous tracings. […] Serum troponin level testing is recommended to aid in the diagnosis of MI and help predict the likelihood of death or recurrent MI within 30 days. […] The likelihood of MI is higher if there is pain radiating to both arms, hypotension, an S3 gallop on physical examination, or diaphoresis.

• #2 ACC/CHEST/AHA/ASECHO/SCCT Evaluation and Diagnosis of Chest Pain Guideline Pocket Guide

  https://www.guidelinecentral.com/guideline/450303/pocket-guide/450307/

  In patients presenting with acute chest pain, serial cTn I or T levels are useful to identify abnormal values and a rising or falling pattern indicative of acute myocardial injury. […] In patients presenting with acute chest pain, high-sensitivity cTn is the preferred biomarker because it enables more rapid detection or exclusion of myocardial injury and increases diagnostic accuracy. […] In patients with acute chest pain and suspected ACS, clinical decision pathways (CDPs) should categorize patients into low-, intermediate-, and high-risk strata to facilitate disposition and subsequent diagnostic evaluation. […] In the evaluation of patients presenting with acute chest pain and suspected ACS for whom serial troponins are indicated to exclude myocardial injury, recommended time intervals after the initial troponin sample collection for repeat measurements are: 1 to 3 hours for high-sensitivity troponin and 3 to 6 hours for conventional troponin assays.

• #2 Evaluation & Diagnosis of Chest Pain | stemiecg

  https://www.stemiecg.com/evaluation-diagnosis-of-chest-pain

  Electrocardiography (ECG) is important in the evaluation of both acute and stable chest pain to assess for evidence of ACS. […] Owing to high sensitivity and specificity for myocardial tissue, serial assessment of cardiac troponin (cTn) I or T is the preferred biomarker for the assessment of myocardial injury among patients with acute chest pain; high-sensitivity cTn is preferred because it allows rapid detection of myocardial injury and has increased diagnostic accuracy. […] Among patients with acute or with stable chest pain, the use of diagnostic testing should be based on a structured assessment of cardiac risk and targeted to patients most likely to benefit. […] Clinically stable patients evaluated for chest pain should be included in clinical decision making, weighing information about costs, risks of adverse events, radiation exposure, and alternative options.

• #2 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP

  https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html

  Evaluating with coronary computed tomography angiography (CCTA) decreases the number of nonfatal acute myocardial infarctions and is moderately more accurate than stress ECG in ruling out CAD in patients with chest pain. […] Cardiac magnetic resonance imaging may be useful in the evaluation of typical angina. […] If the initial evaluation indicates that ACS is less likely or the diagnostic evaluation for ACS in higher-risk patients is negative, other non-ACS conditions that may cause symptoms similar to coronary ischemia should be considered.

• #3

  https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-approach-to/chest-pain

  Assessment of all high-risk patients with chest pain should always begin with getting an initial impression then assessing the airway, breathing and circulation paired with vital signs. […] Chest pain is a team sport. […] Should you have a patient who presents with or develops acute distress or cardiac arrest, your diagnosis and treatment need to occur simultaneously with resuscitating the patient. […] Evaluating chest pain is not simple. […] Serial ECGs, serial biomarkers, clinical assessment, imaging and observation may all still be needed to further differentiate many patients. […] Key features are used in a focused history and physical to rapidly differentiate these critical illnesses. […] High risk patients with undifferentiated chest pain should receive an ECG within 5-10 minutes of arriving to the emergency department.

• #3 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP

  https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html

  The INTERCHEST clinical decision rule is a second validated decision rule that can predict the presence or absence of CAD in patients who present with chest pain in the primary care setting. […] Because history alone usually cannot determine whether a patient is actively experiencing cardiac ischemia, a 12-lead ECG should be performed on all patients in whom cardiac ischemia is suspected. […] ECG findings that increase the likelihood of ACS include ST segment elevation, new-onset left bundle branch block, presence of Q waves, or new T-wave inversions. […] Patients with suspicion of ACS based on clinical presentation (history, physical examination, risk factors) with changes seen on ECG should be transported immediately to the emergency department. […] For patients with chest pain not requiring immediate referral who have a low to intermediate pretest probability of CAD, exercise stress testing should be considered.

• #3 Angina (Chest Pain) – Diagnosis | NHLBI, NIH

  https://www.nhlbi.nih.gov/health/angina/diagnosis

  Your healthcare provider may diagnose angina based on your medical history, a physical exam, and diagnostic tests and procedures. Tests can rule out other conditions and help determine whether you need medical attention right away. […] Your healthcare provider will want to learn about your symptoms and risk factors, such as your personal and family health history, to determine whether your chest discomfort is due to angina or other causes. […] Depending on your symptoms and risk factors, your healthcare provider may want to run some tests to check for medical emergencies. […] An electrocardiogram (ECG) can help recognize types of angina and other serious heart problems. […] A chest X-ray is useful in screening for lung disorders and other causes of chest pain, such as pneumonia and heart failure.

• #3 ACC/CHEST/AHA/ASECHO/SCCT Evaluation and Diagnosis of Chest Pain Guideline Pocket Guide

  https://www.guidelinecentral.com/guideline/450303/pocket-guide/450307/

  In patients with acute chest pain and suspected ACS, previous testing when available should be considered and incorporated into CDPs. […] For patients with acute chest pain, a normal ECG, and symptoms suggestive of ACS that began at least 3 hours before ED arrival, a single hs-cTn concentration that is below the limit of detection on initial measurement is reasonable to exclude myocardial injury. […] In patients with acute chest pain in whom other potentially life-threatening nonischemic cardiac conditions are suspected, TTE is recommended for diagnosis. […] In patients with acute chest pain where there is clinical concern for aortic dissection, computed tomography angiography (CTA) of the chest, abdomen, and pelvis is recommended for diagnosis and treatment planning. […] In stable patients with acute chest pain with high clinical suspicion for PE, CTA using a PE protocol is recommended.

• #3 Patient education: Chest pain (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/chest-pain-beyond-the-basics

  Electrocardiogram — An electrocardiogram (ECG) depicts the progress of the electrical wave through various parts of the heart muscle. In people with ischemic chest pain (caused by the heart not getting enough oxygen-rich blood), there are often changes in the ECG. A normal ECG means that a heart attack is less likely, but it does not rule out angina or a heart attack. […] Blood tests — Blood tests, including tests to measure troponin, creatine kinase (CK), or CK-MB, are used to measure certain enzymes normally found in the heart muscle. During a heart attack, these enzymes leak out of the heart into the blood. Tests of cardiac enzymes are usually repeated over several hours to see if their levels are increasing, which usually indicates a heart attack. […] Stress test — An exercise stress test involves having an ECG while you walk or run on a treadmill. It is also helpful in diagnosing ischemia (when the heart is not getting enough oxygen-rich blood). During this test, the ECG is continuously monitored, looking for evidence of ischemia. If an individual is unable to exercise, a medication can be given to stress the heart. An image of the heart’s response to exercise will often be obtained with an echocardiogram or a nuclear scan.

• #3 Patient education: Chest pain (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/chest-pain-beyond-the-basics

  Cardiac catheterization — Cardiac catheterization, also known as coronary angiography, involves using X-ray guidance to pass a small catheter to the coronary arteries, where dye is injected to show the outline of any blockages. This test is usually recommended for people who are considered to have a high risk of coronary artery blockage based upon the results of other factors, such as their coronary risk factors or the results of the tests described above.

• #3 Diagnosis and treatment of noncardiac chest pain | Nature Reviews Gastroenterology & Hepatology

  https://www.nature.com/articles/ncpgasthep0284

  Chest pain is common: one in four of the population have an episode annually. Of those who present to hospital, nearly two-thirds have noncardiac chest pain. More than half of these cases might have gastroesophageal reflux disease. Opinion differs over what is the most appropriate application of current investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option; if acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including 24-hour or 48-hour esophageal pH testing and esophageal manometry, as well as provocative tests, but there is no consensus as to which methods are the most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders are also common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy, but recent studies have failed to demonstrate an improved outcome using this exhaustive approach. A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of 'therapy as investigation’ might be a superior methodology.

• #3 ACC/CHEST/AHA/ASECHO/SCCT Evaluation and Diagnosis of Chest Pain Guideline Pocket Guide

  https://www.guidelinecentral.com/guideline/450303/pocket-guide/450307/

  In patients with acute chest pain, it is recommended that 9-1-1 be activated by patients or bystanders to initiate transport to the closest ED by emergency medical services (EMS). […] In patients presenting with chest pain, a focused cardiovascular examination should be performed initially to aid in the diagnosis of ACS or other potentially serious causes of chest pain. […] In patients with chest pain in which an initial ECG is nondiagnostic, serial ECGs to detect potential ischemic changes should be performed, especially when clinical suspicion of ACS is high, symptoms are persistent, or the clinical condition deteriorates. […] In patients presenting with acute chest pain, a chest radiograph is useful to evaluate for other potential cardiac, pulmonary, and thoracic causes of symptoms.

• #3

  https://www.cardiosmart.org/news/2021/11/new-guidelines-for-evaluating-diagnosing-and-treating-chest-pain-in-adults

  It is of great importance that the associated symptoms more commonly experienced by women, including palpitations, jaw, neck, and back pain, in addition to underlying factors such as high blood pressure, high cholesterol, and family history, are taken into an evaluation and diagnosis. […] Both acute and stable chest pain need to be evaluated by a clinician, and based on their findings, further testing may be pursued. The proper testing for a patient presenting with acute or stable chest pain is based on their risk of major coronary artery disease (CAD) events. Conducting the appropriate testing based on patient risk not only allows for faster identification of an accurate diagnosis, but it also prevents unnecessary testing, leading to more effective care. […] Clear communication of chest pain descriptors and any associated symptoms by both patients and clinicians using the new AHA/ACC Chest Pain Guideline will likely lead to better utilization of testing, more accurate diagnoses, and quicker treatments, ultimately saving lives while decreasing health care costs.

• #4 Chest Pain – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK470557/

  Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. A workup must focus on ruling out serious pathology before a clinician considers more benign causes. […] Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. A workup must focus on ruling out serious pathology before a physician considers more benign causes. […] In the emergency department, chest pain is the second most common complaint comprising approximately 5% of all emergency department visits. In evaluating for chest pain, the provider should always consider life-threatening causes of chest pain. […] Like all workups, chest pain evaluation starts with taking a complete history. […] Once you have thoroughly ruled out life-threatening causes, move on to other possibilities.

• #4 ACC/CHEST/AHA/ASECHO/SCCT Evaluation and Diagnosis of Chest Pain Guideline Pocket Guide

  https://www.guidelinecentral.com/guideline/450303/pocket-guide/450307/

  In patients presenting with acute chest pain, serial cTn I or T levels are useful to identify abnormal values and a rising or falling pattern indicative of acute myocardial injury. […] In patients presenting with acute chest pain, high-sensitivity cTn is the preferred biomarker because it enables more rapid detection or exclusion of myocardial injury and increases diagnostic accuracy. […] In patients with acute chest pain and suspected ACS, clinical decision pathways (CDPs) should categorize patients into low-, intermediate-, and high-risk strata to facilitate disposition and subsequent diagnostic evaluation. […] In the evaluation of patients presenting with acute chest pain and suspected ACS for whom serial troponins are indicated to exclude myocardial injury, recommended time intervals after the initial troponin sample collection for repeat measurements are: 1 to 3 hours for high-sensitivity troponin and 3 to 6 hours for conventional troponin assays.

• #5

  https://www.nhs.uk/conditions/heart-attack/diagnosis/

  A heart attack is a form of acute coronary syndrome (ACS), where there is a significant blockage in the coronary arteries. […] A STEMI is a type of heart attack where there is a long interruption to the blood supply. This can cause extensive damage to the heart. It’s diagnosed when specific changes show on an ECG. […] An NSTEMI is another type of heart attack where there is some loss of blood supply, causing damage. It’s diagnosed when an ECG does not show the type of changes seen in a STEMI, but blood tests show that the heart is damaged. […] In unstable angina, you have symptoms of a heart attack but tests do not show damage to the heart. […] A chest X-ray can be useful if diagnosis of a heart attack is uncertain and there are other possible causes of your symptoms, such as a pocket of air trapped between the layers of your lungs (pneumothorax).

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