Approach to chest pain

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Approach to Chest Pain

Chest pain is one of the most common and clinically significant presentations in medicine, demanding a systematic approach that first excludes life-threatening causes before addressing other diagnoses.

1. Initial Priorities: Rule Out Life-Threatening Causes First

The three most immediately dangerous causes that must be front-of-mind are:

Condition	Key Feature
Acute Coronary Syndrome (STEMI/NSTEMI/UA)	Substernal pressure/squeezing, radiation to jaw/arm, diaphoresis, nausea
Aortic Dissection	Sudden, tearing/ripping pain radiating to the back; unequal pulses; hypertension or Marfan syndrome
Pulmonary Embolism	Pleuritic chest pain + dyspnea + tachycardia; risk factors (immobility, OCP, DVT)

Other serious causes: pneumothorax (sudden pleuritic pain + absent breath sounds), cardiac tamponade, esophageal rupture (Boerhaave's - pain after retching), and tension pneumothorax.

Goldman-Cecil Medicine, p. 467
Fuster and Hurst's The Heart, 15th Ed.

2. History: The Most Important Diagnostic Tool

Character and Quality

Pressure/squeezing/constriction - typical angina (myocardial ischemia)
Sharp/stabbing, worse with inspiration - pleuritic (PE, pneumothorax, pleuritis, pericarditis)
Tearing/ripping - aortic dissection
Burning - GERD/esophageal; can mimic cardiac
Sharp, localized - musculoskeletal or chest wall

Location and Radiation

Substernal, radiating to neck, jaw, left arm - ischemic; note that radiation can be to neck, shoulder, arm, or wrist - many patients never use the word "pain" and describe pressure or discomfort
Back radiation - ascending dissection typically to back; descending dissection to abdomen
Shoulder radiation from diaphragmatic irritation - pleurisy, diaphragmatic pleurisy

Duration

Angina: <5 minutes with exertion, relieved by rest or nitroglycerin
If lasting >30 minutes, suspect MI unless proven otherwise
Pain lasting hours to days without troponin/ECG changes argues strongly against cardiac ischemia
Sudden onset at maximum intensity - aortic dissection

Precipitants and Relieving Factors

Exertion, cold, emotion, heavy meals - angina
Rest, nitroglycerin - relieves angina (but also esophageal spasm can respond to nitrates, which is misleading)
Lying down, fatty meals, alcohol, coffee - worsens GERD
Pericarditis characteristically relieved by sitting forward
Fuster and Hurst's The Heart, 15th Ed., pp. 1385-1389
Murray & Nadel's Respiratory Medicine, pp. 3536-3548

3. Diamond-Forrester Classification of Chest Pain

This remains clinically useful for pre-test probability of coronary artery disease:

Category	Criteria Met	Definition
Typical angina	3/3	Substernal pressure-like pain; precipitated by exertion or emotional stress; relieved by rest or nitroglycerin within 30 min
Atypical angina	2/3	Two of the three criteria above
Non-cardiac chest pain	0-1/3	Only one or no criterion

Important caveat: Women may present with "atypical" symptoms despite significant CAD. Conversely, the concept that women frequently present atypically may itself be misleading - anginal symptoms may be similar in both sexes. In older men with typical angina, pre-test probability is so high that stress testing for CAD diagnosis may be superfluous.

Fuster and Hurst's The Heart, 15th Ed., pp. 1386-1389

4. Associated Symptoms (Key Clues)

Symptom	Points Toward
Diaphoresis, nausea, vomiting	ACS/MI
Dyspnea	ACS, PE, pneumothorax, heart failure
Hemoptysis	PE, pulmonary infarction
Syncope	Aortic dissection, PE, severe AS, HCM
Dysphagia	Esophageal pathology
Heartburn/regurgitation	GERD
Fever/cough	Pneumonia, pleuritis, pericarditis
Rash along dermatome	Herpes zoster (often precedes rash by days)

5. Physical Examination

General: Appearance, diaphoresis, distress, pallor/cyanosis

Vital Signs:

Tachycardia + hypotension = shock (massive PE, MI, tamponade)
Unequal BP in both arms = aortic dissection
Fever = infection, pericarditis

Cardiovascular:

Pericardial friction rub = pericarditis
New murmur = valvular disease (AS, AR in dissection, MR in papillary muscle rupture)
Raised JVP + muffled heart sounds + hypotension = cardiac tamponade (Beck's triad)
Pulsus paradoxus = tamponade

Respiratory:

Decreased breath sounds unilaterally = pneumothorax or pleural effusion
Egophony, dullness, bronchial breathing = consolidation (pneumonia)

Abdominal: Epigastric tenderness (peptic ulcer, cholecystitis), Murphy's sign

Extremities: Signs of DVT (PE risk), peripheral pulse inequality (dissection)

Chest Wall Palpation: Tenderness that reproduces the pain suggests musculoskeletal/costochondritis, though ~15% of ACS patients may also have reproducible chest wall tenderness

6. Electrocardiogram (ECG) - Mandatory First Investigation

The 12-lead ECG must be obtained within 10 minutes of presentation.

Finding	Diagnosis
ST elevation in leads + reciprocal changes	STEMI (location indicates artery: II/III/aVF = inferior; V1-V4 = anterior)
ST depression + T-wave inversion	NSTEMI/UA (high-risk ACS)
New LBBB	Possible STEMI equivalent
Sinus tachycardia ± S1Q3T3 (right heart strain)	PE
Diffuse saddle-shaped ST elevation + PR depression	Pericarditis
Low voltage + electrical alternans	Tamponade
Normal ECG	Does NOT exclude ACS or other serious diagnoses

7. Investigations

Immediate (All Chest Pain Patients)

12-lead ECG - within 10 minutes
High-sensitivity Troponin (hsTnI or hsTnT) - at 0 hours and 1-3 hours (serial values essential)
Chest X-Ray - widened mediastinum (dissection), pneumothorax, pulmonary edema, infiltrates, cardiomegaly
Oxygen saturation + ABG if respiratory distress

Directed by Clinical Suspicion

Suspected Diagnosis	Test
ACS	Serial troponins, ECG, echocardiography, coronary angiography or CCTA
Aortic dissection	CT angiography chest (definitive), TEE, MRI if stable
Pulmonary embolism	D-dimer (if low-intermediate probability), CT pulmonary angiography, V/Q scan
Pericarditis	Echocardiography, ESR/CRP, viral serology
Pneumothorax	Chest X-ray (expiration film), bedside ultrasound
GERD/esophageal	Upper endoscopy, pH monitoring, PPI trial
Musculoskeletal	Clinical diagnosis; X-ray if rib fracture suspected

8. Risk Stratification: The HEART Score (Emergency Setting)

For undifferentiated chest pain in the ED, the HEART Score is the preferred validated tool:

Variable	0	1	2
History	Non-specific	Mixed elements	Typical ACS features
ECG	Normal	Repolarization abnormality (non-specific)	New ST deviation
Age	<45 years	45-64 years	≥65 years
Risk Factors	None	1-2 risk factors	≥3 risk factors OR known atherosclerotic disease
Troponin	≤normal limit	1-3x upper limit	>3x upper limit

Interpretation:

0-3 (Low risk): ~1.7% MACE rate - safe for early discharge with outpatient follow-up
4-6 (Intermediate risk): ~12-17% MACE - observation + further testing ± cardiology consult
7-10 (High risk): ~50-65% MACE - likely requires coronary intervention, admit

The HEART Pathway adds a second troponin at 3 hours for improved negative predictive value.

Rosen's Emergency Medicine, pp. 1020-1021

9. Differential Diagnosis by System

Cardiac

ACS (STEMI, NSTEMI, unstable angina)
Stable angina
Pericarditis / myocarditis
Aortic stenosis (exertional chest pain)
Hypertrophic cardiomyopathy

Vascular

Aortic dissection
Pulmonary embolism
Pulmonary hypertension (exertional chest pain + dyspnea + cyanosis)

Pulmonary

Pneumothorax
Pneumonia / pleuritis
Pleurisy (sharp, unilateral, respiratory-phase variation, intercostal distribution)
Malignancy (chronic pleuritic pain = mesothelioma)

Gastrointestinal

GERD (burning, worse after meals/lying down, relieved by antacids)
Esophageal spasm (can mimic angina; responds to nitrates - a diagnostic trap)
Peptic ulcer disease
Boerhaave syndrome (esophageal rupture - pain after vomiting)
Cholecystitis

Musculoskeletal

Costochondritis / Tietze syndrome (reproducible tenderness at costochondral junction)
Rib fracture
Precordial catch syndrome (Texidor's twinge in children - sharp, localized, left periapical, worse with inspiration, resolves in minutes)

Neurological / Dermatological

Herpes zoster - may present as chest pain for 2-3 days before rash appears; lancinating/electric shock quality; dermatome distribution

Psychiatric

Panic disorder / anxiety - an important diagnosis of exclusion
Murray & Nadel's Respiratory Medicine, pp. 3515-3561
Rosen's Emergency Medicine (Pediatric)

10. Special Populations

Women: May not use classic "pain" descriptors; may present with nausea, fatigue, or jaw discomfort. Do not assume these are "atypical" and non-cardiac.

Elderly: More likely to present with atypical symptoms (dyspnea, syncope, fatigue) rather than classic chest pain; risk of missing ischemia is higher.

Diabetic patients: May have painless (silent) ischemia due to autonomic neuropathy.

Cocaine users: Chest pain characteristics are identical to atherosclerotic ACS. Manage with aspirin + nitroglycerin. Avoid beta-blockers (risk of unopposed alpha-stimulation); use labetalol (mixed alpha/beta blocker) if rate control needed. IV calcium channel blockers (diltiazem) for ST changes.

Pediatric patients: Most common causes are musculoskeletal, asthma, GERD, and pneumonia. Cardiac causes are rare but must be considered with exertional chest pain, family history of sudden death, or findings suggesting Marfan syndrome.

Tintinalli's Emergency Medicine, Rosen's Emergency Medicine

11. Management Principles by Cause

Cause	Immediate Action
STEMI	Aspirin + P2Y12 inhibitor + anticoagulation; primary PCI within 90 min (door-to-balloon)
NSTEMI/UA	Antiplatelet therapy, anticoagulation, risk stratification, cardiology consult
Aortic dissection	IV labetalol (rate + BP control) → emergent CT angio → surgery (Type A) or medical (Type B)
Massive PE	Anticoagulation; thrombolytics for hemodynamic instability
Tension pneumothorax	Immediate needle decompression, then chest tube
Pericarditis	NSAIDs + colchicine; avoid aspirin alone
GERD	PPI trial; lifestyle modification

Summary Algorithm

Chest Pain
    ↓
Immediately: ECG + IV access + oxygen + troponin + CXR
    ↓
Is this life-threatening?
  → STEMI on ECG? → Activate cath lab
  → Tearing pain + unequal pulses? → CT angio for dissection
  → Pleuritic + hypoxic + tachycardic? → CT-PA for PE
  → Absent breath sounds? → Needle decompression (tension PTX)
    ↓
If none of above immediate threat:
  → Apply Diamond-Forrester classification
  → Calculate HEART Score
  → Serial troponins at 0 and 1-3 hours
  → Consider further imaging (echo, CCTA, stress test)
    ↓
If cardiac excluded:
  → Consider GI, musculoskeletal, pulmonary, dermatological causes

Sources consulted:

Goldman-Cecil Medicine, 26th Ed.
Fuster and Hurst's The Heart, 15th Ed.
Rosen's Emergency Medicine
Tintinalli's Emergency Medicine
Murray & Nadel's Textbook of Respiratory Medicine
Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed.

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