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Feature Article

Differential diagnosis of chest pain: a planned approach to avoid potential pitfalls

Sally McCarthy

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Abstract

A planned approach to the assessment of patients with chest pain presenting in general practice or the emergency department is required to avoid the pitfalls in diagnosing this common presentation. The challenge is to rapidly differentiate between benign and life-threatening causes of chest pain, and to quickly identify patients who require immediate intervention while avoiding over-investigation and unnecessary hospitalisation for those who do not.

Key Points

  • Patients with chest pain present relatively frequently in both general practices and emergency departments.
  • If the clinical appearance of the patient suggests haemodynamic instability, or if the ECG demonstrates an acute ST elevation myocardial infarct or other life-threatening abnormality, an ambulance should be called immediately by dialling 000.
  • In the assessment of chest pain, less common potentially life-threatening causes will be missed unless they are specifically considered, and a stepwise approach can help.
  • Clinical guidance has traditionally focused on the risks of missing potential acute coronary syndrome (ACS), with less attention given to other potentially serious causes or to the cost to the system and individual patient of over-investigation and over-hospitalisation in those at minimal risk.
  • Developments in biomarkers, as well as prospective studies validating expedited risk stratification and clinical decision rules, enable more rapid identification of the cohort of patients requiring intervention for ACS and pulmonary embolism.

    Picture credit: © AJ Photo/SPL.

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