Philosophy of the approach to chest pain diagnosis
While there are many causes of chest pain, the healthcare provider will keep those that are potentially lethal front and center in their evaluation of a patient presenting with chest pain. The big three - heart attack (myocardial infarction), pulmonary embolus, and aortic dissection - should be considered briefly with every patient, although most of the time their presence can be discarded based upon clinical judgment. History and physical examination are key in deciding which path to follow in the diagnosis of chest pain. For somebody who fell and hurt their ribs, that path is well marked. For an elderly person who presents with vague discomfort and risk factors for an illness, significant testing may need to be done to prove that a given diagnosis is not correct.
The concept of ruling out a diagnosis is difficult for some patients to understand. Instead of proving what is happening, the healthcare provider is sometimes charged with proving that a life-threatening diagnosis is not present. "Proving what isn't" takes time and technology. A combination of blood tests and imaging studies may take hours to confirm or refute a diagnosis.
These tests often are done emergently, and treatment may be started even without a firm diagnosis. For example, if a patient presents with chest pain that the healthcare provider believes may be angina, then the initial medications to protect the heart will be started at the same time the diagnostic tests are done. Because some heart tests will take hours to complete, the philosophy exists that heart muscle should not be placed at risk while waiting for a diagnosis. If the heart proves to be normal, then the medications are stopped, and the patient can be reassured that heart disease has been ruled out. Other diagnoses are also considered at the same time the heart tests are being performed, but ruling out one diagnosis does not confirm another.
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