Chest X-ray (CXR)

The CXR is the next investigation commonly performed in the ED for patients presenting with chest pain following initial clinical assessment and ECG (see Figure 1). Table 11 shows the radiographic findings in conditions presenting with chest pain.

The CXR is particularly useful in patients presenting with non-cardiac chest pain and can definitively confirm a diagnosis suspected on clinical grounds (e.g. pneumothorax or pneumonia) or contribute significantly to the diagnostic process (e.g. widened mediastinum in aortic dissection or pneumomediastinum from oesophageal rupture). A normal CXR will also be helpful in making a diagnosis by excluding other potential causes for a certain clinical presentation: for example, a normal CXR in a patient with respiratory distress, pleuritic pain and hypoxia will exclude pneumothorax, make pneumonia unlikely, and increase the probability of pulmonary embolism.

There are no specific diagnostic findings on chest radiography associated with ACS; the usefulness of the CXR in this setting is to exclude other (non-cardiac) causes of chest pain or to evaluate complications of AMI (e.g. pulmonary oedema).

Table 11: Radiographic findings in conditions presenting with chest pain
Condition Radiocraphic Finding Comment
Acute coronary syndrome No specific radiographic finding
Aortic dissection Mediastinal widening
Abnormal aortic contour
Globular heart shadow (haemopericardium)
Pleural effusion (haemothorax)
Suggestive in context
Unusual finding
Rare finding
Rare finding
Pneumothorax Absence of pulmonary vascular markings Diagnostic
Tension pneumothorax Absence of pulmonary vascular markings
Mediastinal displacement
Pneumonia Localised or diffuse pulmonary infiltration
Localised pulmonary atelectasis/consolidation
Diagnostic in context
Pulmonary embolism Normal chest radiograph
Localised pulmonary atelectasis
Small pleural effusion
Suggestive in context
Rare finding
Rare finding
Oesophageal rupture Pneumomediastinum Diagnostic in context
Mediastinitis Pneumomediastinum Diagnostic in context
Pericarditis Globular heart shadow Pericardial effusion
Myocarditis Enlarged cardiac shadow Dilated cardiomyopathy