Evaluation and Management of Pleuritic Chest Pain

Initial Assessment and Risk Stratification

The American College of Cardiology recommends prioritizing the exclusion of life-threatening conditions such as pulmonary embolism, acute coronary syndrome, pneumothorax, pericarditis, and aortic dissection in patients with pleuritic chest pain 1, 2
Obtain vital signs immediately, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation, to assess hemodynamic stability 3
Perform a 12-lead ECG within 10 minutes of presentation to evaluate for STEMI, pericarditis, or signs of right heart strain suggesting pulmonary embolism 3, 4
Draw cardiac troponin immediately upon presentation, even if pleuritic pain characteristics make ischemia less likely 3, 4

Use validated clinical decision rules, such as the Wells score or Geneva score, to determine pretest probability of pulmonary embolism 5
Obtain D-dimer with age-adjusted cutoffs if low-to-intermediate probability of pulmonary embolism 5
Proceed to CT pulmonary angiogram if D-dimer is elevated or if there is a high clinical probability of pulmonary embolism 3, 5
Serial troponin measurements at 3-6 hours if initial troponin is negative but symptoms persist 4
Serial ECGs if initial ECG is nondiagnostic but clinical suspicion remains 4

The American College of Cardiology advises against dismissing pleuritic chest pain as benign without proper workup, as pulmonary embolism remains a significant risk 1, 2
Women and elderly patients require heightened vigilance, as they more frequently present with atypical symptoms 4
Treatment should be targeted at the underlying cause, such as anticoagulation for pulmonary embolism or antibiotics for bacterial pneumonia 5