Cardiovascular Signs and Symptoms: Chest Pain: Evaluation in the Office Setting.

Chest pain is responsible for approximately 1% of primary care encounters. Although most etiologies are benign and self-limited, some reflect underlying pathology associated with significant morbidity and mortality. The initial office evaluation for patients presenting with chest pain should include a comprehensive clinical history, physical examination, and 12-lead electrocardiography to identify those with potential cardiac etiologies. Patients with clinical evidence of acute coronary syndrome or other life-threatening causes of acute chest pain should be transported to the emergency department by emergency medical services. Pretest probability models such as the risk factor-weighted clinical likelihood are helpful for risk-stratifying outpatients with stable chest pain. Risk stratification tools such as the Marburg Heart Score and the International Working Group on Chest Pain in Primary Care rule are also used to stratify outpatients with stable chest pain and identify those at low risk of coronary artery disease who do not require additional testing. For patients with stable angina and intermediate or high risk of coronary artery disease, additional diagnostic testing with coronary computed tomography angiography or stress imaging is recommended. Clinical risk stratification tools such as the Wells criteria should be used to evaluate for pulmonary embolism. Patients with low or intermediate risk of pulmonary embolism should be evaluated with a d-dimer test, whereas those with high risk should have imaging.