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  1. Accurately identify the most likely etiology when patients present with chest pain, through history, diagnostic tests, and patient findings on examination to enable the appropriate recommendation of effective treatment or referral to an appropriate provider.

  2. Use the knowledge of the pathophysiology, etiology, and common presentations of chest pain as a primary symptom to review prescription orders for appropriateness and to accurately educate patients about their disease and its treatment.

In 2006, chest pain and symptoms related to myocardial ischemia were responsible for almost 10% of the 120 million visits to emergency rooms. In the U.S. chest pain and the diseases associated with chest pain are commonly dealt with by pharmacists in almost all practice settings. Approximately, 15 million prescriptions for statins are filled by pharmacists every month, not to mention the larger number of prescriptions for other drugs used to treat angina and causative diseases. National guidelines recommend that most patients discharged after myocardial infarction be placed on as many as four to five medications in addition to their pre-hospital medication regimen. At every visit, pharmacists involved in the management of patients with diabetes, dyslipidemia, and essential hypertension screen patients for symptoms of angina pectoris as a complication of those diseases. Similarly, pharmacists involved in anticoagulation clinics screen for symptoms of pulmonary embolism, a complication of deep vein thrombosis. Therefore, it is important for the pharmacist to understand the various causes of chest pain.


Not all chest pain is cardiac in nature. In addition to angina, pulmonary embolism, pleurisy, pericarditis, esophagitis, various musculoskeletal causes, and hyperventilation may present with symptoms of chest pain. The most common serious cause of chest pain is atherosclerotic heart disease or coronary artery disease. The specific pathological process of how cholesterol-laden plaques build up in the coronary arteries and eventually cause a myocardial infarction is discussed in more detail in the Chapter 19 on dyslipidemia. Atherosclerotic strokes are discussed in the Chapter 13 on headaches. The most common initial symptom of coronary artery disease is angina pectoris. However, the disease can also present either as a ventricular dysrhythmia that causes sudden death or as a myocardial infarction. Plaque buildup begins as young adults slowly increase the occlusion of the coronary arteries. Once a coronary artery reaches 75% occlusion, patients may begin to have symptoms of angina at times of increased myocardial oxygen demand due to exercise, strong emotions, and cold temperatures. Local tissue hypoxia in cardiac muscle creates the classical cardiac pain seen in angina. Occlusions above 90% may lead to chronic hypoxia and symptoms even at rest. Patients with significant plaque deposition are at risk for a myocardial infarction. As part of the process of plaque deposition and eventual occlusion of the artery lumen, an inflammatory process is created between the plaques and the intima of the artery. For unclear reasons, that inflammation eventually causes the plaque to rupture, exposing the intimal ...

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