Chest pain resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]; Alejandro Lemor, M.D. [3]

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Chest Pain Resident Survival Guide Microchapters
Overview
Causes
FIRE
Complete Diagnosis
Cardiac
Non-Cardiac
Treatment
Do's
Don'ts

Overview

Chest pain is defined as a discomfort or pain felt anywhere along the front of the body between the upper abdomen and the neck. The most common causes of chest pain include diseases of cardiac, pulmonary, and gastrointestinal systems. Chest pain is one of the most common complaints in the ER[1] and it is extremely important to rule out life-threatening conditions that need to be managed immediately such as acute myocardial infarction, aortic dissection, esophageal rupture, pulmonary embolism, and tension pneumothorax. To guide the diagnosis and therapy, it is important to characterize the location, intensity, quality, onset, radiation, the alleviating and aggravating factors and the associated symptoms of chest pain. An electrocardiography (ECG) is the most important initial test to diagnose or rule out acute myocardial infarction. The treatment of chest pain depends upon the underlying etiology.

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Cardiac

Cocaine induced coronary vasospasm
Prinzmetal's angina
PCI-induced coronary vasospasm

Pulmonary

Gastrointestinal

Other

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[2][3][4][5]

Boxes in red signify that an urgent management is needed.

Abbreviations: CAD: coronary artery disease; DVT: deep venous thrombosis; ECG: electrocardiogram; ICU: intensive care unit; JVD: jugular venous distension; LBBB: left bundle branch block; NSTEMI: non-ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; TEE: transesophageal echocardiography

 
 
 
 
 
 
 
Order ECG
Order serial cardiac biomarkers (troponins) and CK MB
Perform a bedside echocardiography (if available)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient fulfill the criteria of myocardial infarction?

❑ Rise and/or fall of cardiac biomarker, preferably troponin, with at least one of the measurements >99th percentile of the upper limit of normal

PLUS at least one of the following

❑ Symptoms of ischemia
❑ New ST-T wave changes

ST-T wave changes in STEMI:
ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads, OR
ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI), OR
ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery)

ST-T wave changes in NSTEMI:
❑ No changes
❑ Non specific ST- T wave changes
T wave inversion
ST depression in at least 2 contiguous leads

❑ New LBBB
❑ New Q wave

❑ New regional wall abnormality or new myocardial loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out the following life-threatening conditions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aortic dissection
 
Pulmonary embolism
 
Tension pneumothorax
 
Esophageal rupture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look for supportive symptoms and signs:

❑ Sudden onset of chest pain radiating to the back or interscapular pain
Acute heart failure
Syncope
❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space
❑ Asymmetric blood pressure in the upper extremities
Coma
❑ Diminution or absence of pulse
Altered mental status
❑ Evidence of ischemia

❑ Splanchnic ischemia
❑ Renal insufficiency
❑ Lower extremity ischemia
❑ Focal neurologic deficits
 
Look for supportive symptoms and signs:

Pleuritic chest pain
Dyspnea
Anxiety
❑ History of:

DVT
❑ Recent surgery
Malignancy
❑ Immobility
 
Look for supportive symptoms and signs:

❑ Sudden onset of shortness of breath
Cyanosis
Penetrating chest wound
❑ Flopping sound
❑ Recent medical procedure
❑ Patient on mechanical ventilation
❑ Tracheal deviation towards the unaffected side
❑ Absent heart sound on the affected side

❑ Hyperresonance on the affected side
 
Look for supportive symptoms and signs:

Vomiting
❑ Lower chest pain
Hematemesis
❑ Cervical subcutaneous emphysema
❑ Overindulgence in alcohol

❑ Overindulgence in food
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Click here for the detailed management
 
Click here for the detailed management
 
Click here for the detailed management
 
Click here for the detailed management

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2][3][4]

Abbreviations: ABG: Arterial blood gases; ALT: Alanine transaminase; AST: Aspartate transaminase; CAD: Coronary artery disease; CBC: Complete blood count; COPD: Chronic obstructive pulmonary disease; CXR: Chest X-ray; DVT: Deep venous thrombosis; ECG: Electrocardiogram; GERD: Gastroesophageal reflux disease; GGT: Gamma-glutamyl transpeptidase; HF: Heart failure; JVD: Jugular venous distention; LBBB: Left bundle branch block; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction; P2: Second heart sound, pulmonary component; PE: Pulmonary embolism; S1: First heart sound; S2: Second heart sound; S3: Third heart sound; SLE: Systemic lupus erythematosus; STEMI: ST elevation myocardial infarction; TB: Tuberculosis; TEE: Transesophageal echocardiography; TTE: Transthoracic echocardiography

 
 
 
 
 
 
Characterize the chest pain

❑ Onset (sudden or gradual)
❑ Duration
❑ Frequency
❑ Location (retrosternal, epigastric, chest wall, diffuse)
❑ Type (sharp, pleuritic, heaviness, colicky)
❑ Radiation (shoulder, neck, back, trapezius)
❑ Worsening factors (exertion, position, respiration, drugs)

❑ Alleviating factors (exertion, position, drugs)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize associated symptoms

Non-specific symptoms
Altered mental status
Shortness of breath
Nausea
Vomiting
Dizziness
Syncope
Fatigue
Lethargy

Symptoms suggestive of cardiac etiology
❑ Heaviness or crushing sensation (suggestive of MI)
❑ Radiatiion of the pain to left arm, neck and/or jaw (suggestive of MI)
❑ Interscapular pain (suggestive of aortic dissection)
Epigastric pain (suggestive of inferior MI)
Sweating
Palpitations
❑ Pain associated with exertion
Loss of consciousness

Symptoms suggestive of pulmonary etiology
Pleuritic pain

❑ Sharp or knife-like
❑ Increases with respiratory movements

Dyspnea
Cough
Hemoptysis
❑ Unilateral pain and swelling of lower extremity (suggestive of DVT)
❑ Chills (suggestive of pneumonia)

Symptoms suggestive of gastrointestinal etiology
❑ Burning sensation (suggestive of GERD)
❑ Colic (suggestive of cholelithiasis)
Epigastric pain
❑ Pain is associated with:

❑ Meals (suggestive of GERD or peptic ulcer)
❑ Medication intake (eg: NSAIDs)
Swallowing
❑ Changes in position
❑ Wakening during night (suggestive of GERD)
❑ Relieved by antacids
❑ Not related to exercise
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about past medical history and risk factors

❑ Previous episodes of chest pain
❑ Cardiovascular disease

❑ Previous MI
DVT
Hypertension
❑ Family history of CAD

❑ Recent medical procedures

Central venous catheter placement (suggestive of pneumothorax)
Bronchoscopy (suggestive of pneumothorax)
❑ Pleural biopsy (suggestive of pneumothorax)

❑ Pulmonary disease

❑ Previous PE
COPD
Asthma

Malignancy
❑ Recent viral infection (suggestive of pericarditis or pneumonia)
❑ Recent trauma
❑ Recent surgery (<3 months) (suggestive of PE)
Psychiatric disorders
Alcohol intake
Smoking
Cocaine use
Methamphetamine use
Hyperlipidemia
❑ Rheumatic disorders

SLE
Rheumatoid arthritis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient

Vitals
Fever (non-specific)
Heart rate

Tachycardia (non-specific)
Bradycardia

Blood pressure in both arms

Hypertension
Hypotension
Narrow pulse pressure (suggestive of aortic stenosis)
❑ Asymmetric blood pressure in extremities (suggestive of aortic dissection)

Tachypnea (non-specific)

General appearance
Pale
Diaphoretic
❑ Severe distress

Neck
JVD (suggestive of pericarditis or pulmonary hypertension)
Kussmaul sign (suggestive of pericarditis)

Cardiovascular examination
Palpation
❑ Pain on palpation of chest wall (suggestive of costochondritis)
Apical impulse (suggestive of LVH in aortic stenosis)
Pulses
Pulsus parvus et tardus (suggestive of aortic stenosis)
Pulsus paradoxus (suggestive of pericarditis)
Auscultation
❑ Carotid or femoral bruits (suggestive of vascular disease)
❑ Presence of S3 and/or S4
Paradoxical splitting of S2 (suggestive of aortic stenosis)
Muffled heart sounds (suggestive of pericarditis)
Pericardial friction rub (suggestive of pericarditis)
Systolic murmur (suggestive of aortic stenosis or hypertrophic cardiomyopathy)
Diastolic murmur (suggestive of aortic dissection)

Respiratory examination
❑ Shift of the trachea from midline (suggestive of tension pneumothorax)
Hyperresonance over the affected side (suggestive of tension pneumothorax)
Auscultation of the lungs
❑ Absent breath sounds in one hemithorax (suggestive of pneumothorax)
Rales (suggestive of HF or pneumonia)
Wheezing (suggestive of asthma or COPD)
Pleural rub (pleuritis

Abdominal examination
❑ Positive Murphy's sign (suggestive of acute cholecystitis)
❑ Resonant percussion over the liver (suggestive of perforated peptic ulcer)
❑ Tenderness over the epigastrium (suggestive of gastrointestinal etiology)
Rectal examination that shows occult bleeding (peptic ulcer)

Neurological examination
Focal abnormalities (suggestive of stroke due to aortic dissection)

Hemiparesis
Vision loss
Aphasia
Hypertonia

Skin
Unilateral vesicular rash located in one or two adjacent dermatomes (suggestive of herpes zoster)
Jaundice (suggestive of acute cholecystitis)

Xanthoma (suggestive of dyslipidemia)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests according to the suspected etiology
In high suspicion of MI, do not delay initial management
ECG, consider serial ECG's (most important initial test)
Troponin and CK-MB, serial measurements: at presentation, and 6 to 12 hours after onset of symptoms
CBC
Amylase / Lipase
AST and ALT
Alkaline phosphatase and GGT
Bilirubin
ABG
D-dimer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imaging studies
According to the suspected etiology
Chest X-ray (to rule out pneumothorax or pneumonia)
Echocardiography (to rule out aortic stenosis or aortic dissection)
CT angiography (to rule out pulmonary embolism)
Upper endoscopy (to rule out peptic ulcer or GERD)
RUQ ultrasound (to rule out acute cholecystitis)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the chest pain have any of the following findings suggestive of cardiac etiology?

❑ Pain described as a heaviness or crushing sensation
❑ Radiation of the pain to the left arm, neck and/or jaw
❑ Associated symptoms of:
Diaphoresis
Dyspnea
Nausea
Vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Click here for the cardiac chest pain approach
 
 
 
 
 
Click here for the non-cardiac chest pain approach
 

Cardiac Chest Pain

Click on each disease shown below to see a detail approach for every cardiac cause of chest pain.

 
 
 
 
 
 
 
Does the ECG show any of the following:

ST- T wave changes, OR
❑ New LBBB, OR

❑ New Q wave
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are the ECG changes confined to an anatomic area?
 
 
 
 
 
 
 
Does the TTE show valve or aortic abnormalities?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following:

Myocardial infarction*
❑ Pain described as a substernal pressure or crushing sensation
❑ Pain radiation to the left arm, neck and/or jaw
Dyspnea
❑ Associated with diaphoresis, nausea or vomiting
❑ Not alleviated by rest or medications
CK-MB and troponin elevation
❑ ECG changes

❑ New ST-T wave changes
ST-T wave changes in STEMI:
❑ ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads, OR
❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI), OR
❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery)
ST-T wave changes in NSTEMI:
❑ Non specific ST- T wave changes
❑ T wave inversion
❑ ST depression in at least 2 contiguous leads
❑ New LBBB
❑ New Q wave

Coronary vasospasm

Prinzmetal's angina
PCI-induced coronary vasospasm
Cocaine induced
 
Consider the following:

Pericarditis
❑ Sharp and pleuritic pain
❑ Pain radiation to trapezius
❑ Pain increase on inspiration
❑ Pain improved by sitting up and leaning forward
❑ Pericardial friction rub
❑ Diffuse, non-specific ST elevation
PR depression
❑ PR elevation in lead aVR
Fever
Cough
Pericardial friction rub

Myopericarditis
❑ Similar symptoms and signs to pericarditis
❑ Symptoms of heart failure
❑ Elevated troponins
 
 
 
Consider the following:

Myocardial infarction*
❑ Elevated cardiac enzymes, PLUS
❑ New regional wall abnormality or new myocardial loss

Aortic stenosis
❑ Systolic ejection murmur with ejection click

❑ Best heard at the upper right sternal border
❑ Bilateral radiation to the carotid arteries

TTE findings of stenosis
❑ Exertional dyspnea
Syncope

Aortic dissection
❑ Acute mid-scapular knifelike, tearing pain
❑ Discrepancy of blood pressure (> 20mmHg) between two arms
❑ Decreased pulses
❑ Low or high blood pressure
❑ Focal neurological deficit
❑ Low pitched early diastolic murmur best heard at the 2nd right ICS
Widened mediastinum on chest X-ray
TEE findings of:

❑ Intimal tear
Aortic regurgitation

❑ History of:

Hypertension
Marfan syndrome
 
Consider the following:

Myocardial infarction*
❑ Elevated cardiac enzymes, PLUS
❑ Symptoms of ischemia

Stable angina
❑ Pain described as a heaviness or crushing sensation
❑ Normal value of cardiac enzymes
❑ Pain usually lasts < 10 min
❑ Provoked by exertion or stress
❑ Improves with rest or nitroglycerin
 
  • Myocardial infarction is defined as positive biomarkers (rise and/or fall) plus at least one of the following: ischemia symptoms, ST-T wave changes confined to a regional territory, new LBBB, new pathological Q wave, and new regional myocardial wall abnormality or loss.


Non-Cardiac Chest Pain

Click on each disease shown below to see a detail approach for every non-cardiac cause of chest pain.

 
 
 
 
 
 
 
 
 
Determine the non-cardiac etiology based on the physical examination and tests findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary
 
 
 
 
Gastrointestinal
 
 
 
Other
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the onset sudden?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following:

Pulmonary embolism
❑ Sudden chest pain
Dyspnea
❑ History of DVT, surgery, malignancy, immobility
❑ Increase respiratory rate
❑ Increase heart rate
❑ Elevated D-dimer
Hypoxia

Pneumothorax
❑ Sharp pleuritic pain
❑ Sudden onset of dyspnea
Tracheal deviation towards the unaffected side
Hyperresonance on the affected side
❑ Hyperresonance
Hypoxia

Asthma exacerbation
❑ Acute shortness of breath
Wheezing
❑ History of asthma
 
Consider the following:


Pulmonary hypertension
Dyspnea on exertion
❑ Increased P2
❑ History of gradual onset of shortness of breath
R3 or R4
JVD
❑ Lower extremity edema

Bacterial pneumonia
Productive cough
Fever
Dyspnea
❑ Increased respiratory rate
Crackles
❑ New infiltrate on the CXR

Pulmonary TB
Cough
Hemoptysis
Night sweats
❑ Weight loss
❑ Cavitary lesion on CXR

Pleurisy
❑ Sharp pain associated with inspiration and expiration
❑ Shallow breathing
Pleuritic friction rub
❑ Search for an underlying cause
 
 
Consider the following:

Pancreatitis
❑ Severe epigastric pain radiating to the back
Nausea and vomiting
❑ Increased levels of amylase or lipase
❑ History of alcohol intake or gallstones

Acute cholecystitis
❑ RUQ pain associated with meals
❑ Radiation to right shoulder
Nausea and vomiting
Jaundice
❑ Positive Murphy's sign

GERD
❑ Burning sensation from the epigastrium towards the throat
❑ Symptoms occur following meals
❑ Duration of symptoms: minutes to hours

Peptic ulcer
Epigastric pain:

❑ Starts 5-15 min after a meal (suggestive of gastric ulcer)
❑ Alleviated by meals (suggestive of duodenal ulcer)

❑ Alleviated by antacids

Esophageal spasm
❑ Intermittent intense substernal pain
❑ Worsen by swallowing
❑ Alleviated by nitroglycerin or CCB
Dysphagia

Mallory-Weiss syndrome
❑ Epigastric ± back pain
❑ History of vomiting
Hematemesis
 
 
 
Consider the following:

Musculoskeletal pain
❑ Localized pain
❑ Reproducible pain on palpation of costochondral joints
❑ Exacerbated by chest wall movements
❑ History of rheumatoid arthritis

Herpes zoster
❑ Burning pain localized in a dermatome
❑ Unilateral vesicular rash
❑ History of immunosuppresion or severe stress

Psychiatric conditions
Anxiety
Hypochondriasis
Panic attack
 

Treatment

The management of chest pain will depend on the underlying cause. Click on each disease shown below to see a detail management for every cause of chest pain.
Abbreviations: GERD: Gastroesophageal reflux disease; NSTEMI: Non-ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction

CARDIAC PULMONARY GASTROINTESTINAL OTHER
STEMI / LBBB
NSTEMI / Unstable angina
Stable angina
Pericarditis
Aortic dissection
Aortic stenosis
Prinzmetal's angina
PCI-induced coronary vasospasm
Cocaine induced coronary vasospasm
Pulmonary embolism
Pneumothorax
Asthma exacerbation
Pulmonary hypertension
Pneumonia
Pleuritis
Pancreatitis
Acute cholecystitis
GERD
Peptic ulcer
Esophageal spasm
Mallory-Weiss syndrome
❑ Musculoskeletal pain:
Costochondritis
Rheumatoid arthritis
Rib fracture

Herpes zoster
Anxiety
Panic disorder

Do's

Don'ts

References

  1. Bhuiya F, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999–2008. NCHS data brief, no 43. Hyattsville, MD: National Center for Health Statistics. 2010. http://www.cdc.gov/nchs/data/databriefs/db43.pdf
  2. 2.0 2.1 "2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 127 (23): e663–e828. 2013. doi:10.1161/CIR.0b013e31828478ac. ISSN 0009-7322.
  3. 3.0 3.1 Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE; et al. (2012). "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 60 (7): 645–81. doi:10.1016/j.jacc.2012.06.004. PMID 22809746.
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  5. Torbicki, A.; Perrier, A.; Konstantinides, S.; Agnelli, G.; Galie, N.; Pruszczyk, P.; Bengel, F.; Brady, A. J.B.; Ferreira, D.; Janssens, U.; Klepetko, W.; Mayer, E.; Remy-Jardin, M.; Bassand, J.-P.; Vahanian, A.; Camm, J.; De Caterina, R.; Dean, V.; Dickstein, K.; Filippatos, G.; Funck-Brentano, C.; Hellemans, I.; Kristensen, S. D.; McGregor, K.; Sechtem, U.; Silber, S.; Tendera, M.; Widimsky, P.; Zamorano, J. L.; Zamorano, J.-L.; Andreotti, F.; Ascherman, M.; Athanassopoulos, G.; De Sutter, J.; Fitzmaurice, D.; Forster, T.; Heras, M.; Jondeau, G.; Kjeldsen, K.; Knuuti, J.; Lang, I.; Lenzen, M.; Lopez-Sendon, J.; Nihoyannopoulos, P.; Perez Isla, L.; Schwehr, U.; Torraca, L.; Vachiery, J.-L. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". European Heart Journal. 29 (18): 2276–2315. doi:10.1093/eurheartj/ehn310. ISSN 0195-668X.
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