Preface

Cardiovascular disease continues to be the leading cause of morbidity and mortality in both developed and developing countries. Chest pain is one of the common and distressing presentations of cardiovascular disease. The number of patients presenting to emergency rooms or to their healthcare providers with chest pain is ever-growing and constitutes one of the most common reasons to seek medical help. Out of these patients with chest pain, cardiovascular cause constitutes about 20% of the patients, and out of which only 5% is a truly acute life-threatening disease. Hence, it is very important to have a systematic approach to patients with chest pain. The clinical scenario is the most important factor to differentiate the various causes of chest pain so that these patients can be treated at the earliest to avoid a bad outcome. It also vital to diagnose non acute/non cardiac chest pains and decipher their etiology as these patients could be frequently visiting the health care providers without a proper diagnosis.

This book aims to provide an excellent overview of the differential diagnosis and approach to chest pain in various clinical settings. This book is divided into two sections including the introduction and approach to chest pain. Our introductory chapter starts with the basic principles of statistics and its application in various diagnostic modalities of heart disease. Our authors present a nice approach to patients presenting with chest pain in various scenarios. We have also included a chapter describing GERD, which could present as chest pain and another chapter describing aortic dissection, which is a life-threatening disease presenting with chest pain. We hope that this book will serve as an accessible handbook on differential diagnosis of chest pain.

I gratefully acknowledge the invaluable organizational skills of the publisher IntechOpen, timely, patient and invaluable assistance of Author Service Manager Ms. Dolores Kuzelj, designer, technical generators, information technology staff and finally the marketing representatives who are working constantly to promote the book on various platforms. I sincerely appreciate and applaud all the contributing authors for their excellence, hard work and commitment to the chapters. They have taken time from their personal and professional lives to complete this task. I thank them profusely for that.

This book is dedicated to my son Shawn who continues to inspire me, making my life blissful and giving me the confidence that every generation is better than the one before.

> **Umashankar Lakshmanadoss MD, CCDS, FHRS** Mercy Heart Institute, Cincinnati, OH, USA

**1**

Section 1

Introduction

Section 1 Introduction

**3**

**Chapter 1**

*John-Ross D. Clarke*

**1. Background**

Introductory Chapter: The Patient

Chest pain is the principal reason for approximately 5% of the emergency department (ED) visits in the United States [1]. It is the most frequent reason for presentation to an emergency facility in men age 65 years and older. In some cohorts, chest pain accounts for up to 16% of ambulance transports and constitutes almost 30% of emergency admissions [2, 3]. In the primary care setting however,

Part of the significance of chest pain as a presenting symptom is its association with potentially life-threatening diagnoses such as: acute myocardial infarction (AMI), pulmonary embolism, and aortic dissection, among others. The challenge for the clinician is the accurate stratification of patients based on risk, and the efficient and cost-effective utilization of resources to establish a diagnosis. The first step in diagnosis is an informed history and physical examination- which is not without limitations even in the most experienced hands [5]. The sections that follow provide a brief insight into the scope of chest pain diagnoses and the value of

The differential diagnosis of a patient presenting with chest pain is extensive [6]. A systematic approach is therefore needed to (i) determine the likelihood of an immediately life-threatening cause, (ii) differentiate cardiac from noncardiac etiologies, and (iii) reduce over-diagnosis and thus overutilization of healthcare resources in the subsequent investigation. This approach not only increases the diagnostic accuracy and efficiency of workup, but also leads to better patient and

There are innumerable ways of categorizing the differential diagnosis of chest pain. Potential categorization approaches are: (i) cardiac vs. noncardiac etiologies (ii) classifying based on symptom characteristics, (iii) by organ systems and (iv) anatomically (**Figure 1**). An anatomic approach allows for an exhaustive differential diagnosis but does have limitations in refinement based on pre-test probabilitythis subsequent step requires the incorporation of other aspects of symptom

A schema for classifying causes of chest pain anatomically includes structures from the skin to internal organs of the thorax and upper abdomen (**Figure 1**).

Presenting with Chest Pain

less than 1% of visits are for a chief complaint of chest pain [4].

clinical findings in establishing a diagnosis.

clinician satisfaction [7].

presentation [6].

**2. The differential diagnosis of chest pain**

## **Chapter 1**
