Chest Pain (cont.)
Philosophy of the approach to chest pain diagnosis
While there are many causes of chest pain, the healthcare provider will keep
those that are potentially lethal front and center in their evaluation of a
patient presenting with chest pain. The big three - heart attack (myocardial
infarction), pulmonary embolus, and aortic dissection - should be considered
briefly with every patient, although most of the time their presence can be
discarded based upon clinical judgement.
History and physical examination are key in deciding which path to follow in
the diagnosis of chest pain. For somebody who fell and hurt their ribs, that
path is well marked. For an elderly person who presents with vague discomfort
and risk factors for an illness, significant testing may need to be done to
prove that a given diagnosis is not correct.
The concept of ruling out a diagnosis is difficult for some patients to
understand. Instead of proving what is happening, the healthcare provider is
sometimes charged with proving that a life-threatening diagnosis is not present.
"Proving what isn't" takes time and technology. A combination of blood tests and
imaging studies may take hours to confirm or refute a diagnosis.
These tests often are done emergently, and treatment may be
started even without a firm diagnosis. For example, if a patient presents with
chest pain that the healthcare provider believes may be angina, then the
initial medications to protect the heart will be started at the same time the
diagnostic tests are done. Because some heart tests will take hours to complete,
the philosophy exists that heart muscle should not be placed at risk while
waiting for a diagnosis. If the heart proves to be normal, then the medications
are stopped, and the patient can be reassured that heart disease has been ruled
out. Other diagnoses are also considered at the same time the heart tests are
being performed, but ruling out one diagnosis does not confirm another.
Next: What is the diagnosis and treatment for cause of chest pain? »
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