Chest pain is one of the most serious of all patient complaints, and accounts for 1% of primary care outpatient visits. It is the most common symptom of coronary heart disease (CHD), which affects over 15 million Americans age ≥20 years. In 2012, the prevalence of MI was 7.6 million people and of angina pectoris, 8.2 million. CHD is the leading killer of both men and women. In 2011, CHD accounted for one in seven U.S. deaths. Death rates remain highest for black men and black women compared to other ethnic groups.

As you evaluate your patient's history of chest pain, always consider life threatening diagnoses such as angina pectoris, MI, dissecting aortic aneurysm, and pulmonary embolus. Learn to distinguish cardiovascular causes from disorders of the pericardium, trachea and bronchi, parietal pleura, esophagus, and chest wall, and from extrathoracic causes in the neck, shoulder, gallbladder, and stomach.

Both men and women with acute coronary syndrome usually present with the classic symptoms of exertional angina; however, women, particularly those over age 65, are more likely to report atypical symptoms that may go unrecognized, such as upper back, neck, or jaw pain, shortness of breath, paroxysmal nocturnal dyspnea, nausea or vomiting, and fatigue, making careful history taking especially important. Failure to identify cardiac causes of chest pain can have dire consequences. Inappropriate discharge from the emergency room results in a 25% mortality rate.

Begin with open-ended questions… "Please tell me about any symptoms you might be having in your chest." Then elicit more specific details. Ask the patient to point to the pain and describe all seven features of the symptom. Clarify "Is the pain related to exertion?" and "What kinds of activities bring on the pain?" Also, "How intense is the pain, on a scale of 1 to 10?"… "Does it radiate into the neck, shoulder, back, or down your arm?"… "Are there any associated symptoms like shortness of breath, sweating, palpitations, or nausea?"… "Does it ever wake you up at night?"… "What do you do to make it better?"

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