Emergency Department Evaluation of Pleuritic Chest Pain

Initial Assessment and Diagnostic Considerations

The American College of Cardiology recommends obtaining a focused history and performing a focused cardiovascular examination to aid in diagnosis of serious causes, such as pulmonary embolism, aortic dissection, and pneumothorax, in patients with pleuritic chest pain 1, 2, 3
The American Heart Association suggests acquiring and reviewing an ECG within 10 minutes of arrival to evaluate for STEMI or other concerning findings in patients with acute chest pain 1, 4
Measurement of cardiac troponin is recommended as soon as possible after presentation in all patients with acute chest pain and suspected acute coronary syndrome (ACS) 1, 5
The American College of Cardiology recommends considering pulmonary embolism even when chest radiograph, ECG, and arterial blood gases are normal, and using validated clinical decision rules to guide further testing 6

Pericarditis typically presents with fever, pleuritic chest pain that worsens when supine, and pericardial friction rub, and the American College of Cardiology recommends ordering inflammatory markers and considering echocardiography 1, 5
Pneumothorax presents with dyspnea and pain on inspiration, unilateral absence of breath sounds, and the American College of Cardiology recommends chest radiography for diagnosis 1, 6
The American College of Cardiology suggests considering myocarditis in patients with fever, chest pain, and heart failure, and aortic dissection in patients with severe pain and abrupt onset, pulse differential, and widened mediastinum on chest radiography 1, 6
Women with pleuritic chest pain are at risk for underdiagnosis of ACS, and the American College of Cardiology recommends obtaining a history emphasizing accompanying symptoms more common in women with ACS 2, 3
Older patients (≥75 years) with pleuritic chest pain should be considered for ACS when accompanying symptoms such as shortness of breath, syncope, or acute delirium are present, according to the American College of Cardiology 3, 6