Abstract
We read with interest “Non-Cardiac Chest Pain: Management in the Ambulatory Clinic setting” (Acute Med 2019;18(3)165-70). It is useful to know about the various musculoskeletal causes of chest pain, especially where specific treatment may be available. We were alarmed, however, about the discussion of pleural pain. This is a common presenting complaint to acute medical teams both on the acute medical take and on ambulatory care units. The authors do not list a differential diagnosis for pain of pleural origin, apart from pulmonary embolism. A chest radiograph is recommended, as well as either a WELL’s (sic) score or D-dimer. Furthermore, bedside lung ultrasound is recommended if the chest radiograph is normal, despite limited availability and training in the UK. Ironically, the reference provided (Aydogdu M et al, Tuberk Toraks 2014;62:12-21) is much more reflective of the modern approach to suspected pulmonary embolism. It discusses the PERC (PE rule-out criteria) which perform very well in people who present with chest pain, and reduces reliance on D-dimer testing. D-dimer testing should never be performed without determining a pre-test probability using validated scores such as the Wells score. As the authors suggest, not all chest pain that worsens with inspiration is “pleuritic”. In addition, substernal pain with a respiratory component does not increase the likelihood of PE, whereas lateral and posterior pain does (Kline J, Thomb Res 2018;163:207-20). Kind regards, Jacob F. de Wolff FRCP Katherine M. Fawcett FRCP Consultant Acute Physicians Northwick Park Hospital
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