Which Test is Best for Pain in the Chest?

Chest pain is one of the most common chief complaints seen in both the emergency department (ED) and primary care settings.1,2 It is estimated that 20-40% of the general population will suffer from chest pain at some point throughout their lives.3 Interestingly although obstructive coronary artery disease (CAD) prevalence has declined, chest pain as a presenting symptom has become increasingly common over the last decade.4 Chest pain can stem from different organ systems including cardiac, pulmonary, gastrointestinal, musculoskeletal, or psychiatric.5,6 However, only about 18% of chest pain is diagnosed as cardiac in nature.7 Cardiac chest pain, in itself, has a broad differential including ischemic CAD, but can also be a result of non-ischemic causes such as valvopathies, myocarditis, pericarditis, aortic dissection, or heart failure.8 Ischemic chest pain can be broken into life-threatening acute coronary syndrome (ACS), unstable angina, or stable angina. Discerning the etiology of chest pain based on history and physical exam alone is challenging as symptomatology can overlap with multiple organ systems.9 Therefore, physicians often rely on testing to reach a diagnosis, a practice which costs the United States healthcare system billions of dollars per year.4 In this review, we aim to identify the cardiac-testing modalities available to clinicians to accurately diagnose a cause of chest pain and consider which test might be most appropriate for patients evaluated in the ambulatory or ED setting.