Physicians will consider a number of factors when attempting to determine the cause of a patient’s chest pain. Because certain cardiac causes of chest pain are life-threatening (e.g., heart attack) and require immediate treatment, physicians will often focus on ruling out heart disorders first. Physicians may also test for life-threatening lung conditions, including pulmonary embolism, aortic dissection and pneumothorax.

An evaluation for chest pain may begin with a physician taking the patient’s medical history and performing a physical examination. These steps can provide a physician with important clues and help them determine the cause of the chest pain.

While collecting a patient’s medical history, physicians may ask questions aimed at determining if the patient has cardiac risk factors. Patients may be asked to complete a pain assessment or be asked a number of questions about pain, including:

• Where is the pain located? Does the location of the pain change?
  
  
• Does the pain radiate to other areas of the body (e.g., neck, back, jaw, shoulder, arm)?
  
  
• What does the pain feel like (e.g., severe, tearing or ripping, sharp, stabbing, burning, constricting, pressure-like, aching, dull, heavy)?
  
  
•  Does the pain occur suddenly or gradually?
  
  
• Does the pain appear at the same time each day?
  
  
• How long does the pain last?
  
  
• Is the pain getting worse?
  
  
• Are there any activities that cause the pain to intensify (e.g., deep breathing, coughing, eating, bending over)?
  
  
• Does pain occurring during exercise improve with rest? If so, is the pain completely relieved or just slightly improved?
  
  
• Are there any factors that relieve the pain (e.g., nitroglycerin medication, drinking milk, taking antacids, belching)?
  
  
• Do any other symptoms accompany the pain?

The evaluation will include monitoring of the patient’s vital signs, including pulse rate, blood pressure, rate of breathing and temperature. During the physical examination a physician will focus on examining the chest wall, lungs and heart. A cardiac examination may be performed. This may include auscultation (listening to sounds of the organs with a stethoscope) to look for symmetry of breathing sounds, wheezing or crackling. Physicians may also perform palpitation (feeling) of the chest wall. This will enable them to locate areas of tenderness. An examination of the abdomen may also be performed.

A number of tests are usually required to determine the cause of chest pain. This allows physicians to eliminate a number of causes and close in on an exact source. Information provided in the patient’s medical history and factors revealed in the physical examination are used to determine which tests to order. These may include:

• Blood tests. These tests determine the amount of any given substance in a blood sample. Increased levels of certain enzymes in the blood may indicate heart damage, such as that caused by a heart attack. Blood tests ordered during an evaluation for chest pain may include LDH (lactate dehydrogenase) tests, LDH isoenzymes tests, CPK (creatine phosphokinase) tests, CPK isoenzymes tests, troponin tests, complete blood counts and blood differential tests.
  
  
• Electrocardiogram (EKG or ECG). This test records the electrical activity of the heart through electrodes attached to the skin. The activity is recorded as waves displayed on a monitor or a moving strip of paper. ECG can reveal the presence of heart damage because injured heart muscle does not conduct electrical impulses normally. ECGs can help physicians diagnose a number of heart disorders, including heart attack that has occurred or is in progress.
  
  
• Exercise stress test. Also known as an exercise EKG, an exercise stress test measures how the heart and blood vessels respond to physical exertion. During the test, patients hooked up to an EKG may be asked to walk on a treadmill or pedal a stationary bicycle. In some cases the patient receives a drug intravenously to stimulate the heart. This test, which is sometimes used in combination with echocardiography and radionuclide imaging (a procedure in which radioactive material is introduced into the body for the purpose of imaging), can reveal if chest pain is related to the heart. It is one of the most common tests performed to diagnose coronary artery disease.
  
  
• Upper endoscopy. A camera mounted on a flexible tube (endoscope) is inserted through the mouth and down the throat. This allows the physician to inspect the esophagus, stomach and the upper portion of the small intestine. This test may reveal gastroesophageal (involving the stomach and esophagus) disorders that can cause chest pain. A biopsy may be performed so a tissue sample from the stomach can be analyzed to rule out conditions such as stomach cancer. Endoscopy is typically performed in a hospital with the patient under anesthesia.
  
  
• Cardiac catheterization. A catheter (a thin flexible tube) is inserted through a blood vessel, usually in the groin, and passed into the right or left side of the heart. This enables physicians to obtain diagnostic information about the heart and its blood vessels, including pressure and blood flow in the heart’s chambers.

Possible imaging studies include:

• Chest x-rays. An x-ray is a painless test in which an image is created of part of the body. It uses low doses of electromagnetic radiation that are reflected on film or fluorescent screens. Chest x-rays enable physicians to examine the condition of the heart, lungs and major blood vessels.
  
  
• Electron beam computerized tomography (EBCT). This advanced, fast form of CAT scan may be used to scan the arteries for signs of calcium deposits. The presence of calcium often suggests that fatty deposits may be accumulating and blocking the arteries supplying blood to the heart.
  
  
• MRI (magnetic resonance imaging). MRIs use a powerful magnetic field to create images of structure and organs within the body allowing a computer to produce clear cross-sectional or three-dimensional images. These tests may be ordered to determine if a patient’s chest pain is related to a cardiac problem.
  
  

  

• Echocardiogram. This form of ultrasound uses sound waves to create a moving image of the heart. These tests are helpful in an evaluation of chest pain because they can reveal heart problems.
  
  
• Lung scan. A form of radionuclide imaging, a lung scan involves injecting a small amount of radioactive gallium into a patient’s vein. At a later time, a scanner (gamma camera) is moved over the patient’s body to detect the gamma rays emitted by the gallium. The information picked up by the camera is then transmitted to a computer which displays an image on its screen.
  
  
• Angiogram. An x-ray machine is used to provide a clear picture while contrast medium (dye) is injected into one of the patient’s arteries. The arteries become visible to an x-ray machine as they fill up with the dye. As a result, physicians are able to identify individual arteries that may be narrowed or blocked.

Scientists report that a new radioactive tracer, iodofiltic acid I 123, can be used with a nuclear imaging technique called a SPECT scan to distinguish cardiac causes from noncardiac causes up to 30 hours after a patient experiences chest pain. Further research will be needed before this test may become a standard diagnostic tool.