The 5 Life-Threatening Causes of Chest Pain
The five major life-threatening causes of chest pain are Acute Coronary Syndrome (ACS), Pulmonary Embolism (PE), Aortic Dissection, Tension Pneumothorax, and Esophageal Rupture. 1
1. Acute Coronary Syndrome (ACS)
Clinical Presentation
- Typical symptoms: Substernal chest pain/pressure, radiation to arm/jaw/neck
- Associated symptoms: Diaphoresis, nausea, dyspnea
- Physical findings: May include tachycardia, hypotension, S3 gallop, mitral regurgitation murmur
- Note: Examination may be completely normal in uncomplicated cases 1
Key Diagnostic Features
- ECG: ST-segment elevation (STEMI) or depression/T-wave inversions (NSTEMI/UA)
- Cardiac biomarkers: Elevated troponins
- Risk increases with age >65 years, known cardiovascular disease, multiple risk factors
2. Pulmonary Embolism (PE)
Clinical Presentation
- Symptoms: Pleuritic chest pain, dyspnea (present in >90% of patients)
- Physical findings: Tachycardia, tachypnea, pain with inspiration 1
- May present with hypoxemia, hemoptysis, or signs of right heart strain
Key Diagnostic Features
- Risk factors: Immobility, recent surgery, malignancy, pregnancy, oral contraceptives
- ECG: May show sinus tachycardia, right heart strain pattern (S1Q3T3)
- D-dimer typically elevated (though not specific)
3. Aortic Dissection
Clinical Presentation
- Symptoms: Sudden, severe "tearing" chest or back pain
- Physical findings: Pulse differential between extremities (present in 30% of patients) 1
- Associated findings: Syncope (>10% of cases), aortic regurgitation murmur (40-75% in type A) 1
Key Diagnostic Features
- Risk factors: Hypertension, connective tissue disorders (e.g., Marfan syndrome)
- Combination of severe pain with abrupt onset + pulse differential + widened mediastinum on CXR has >80% probability of dissection 1
- Type A (ascending aorta) is more immediately life-threatening than Type B
4. Tension Pneumothorax
Clinical Presentation
- Symptoms: Sudden-onset pleuritic chest pain, progressive dyspnea
- Physical findings: Unilateral decreased or absent breath sounds, hyperresonance to percussion 1
- Late findings: Tracheal deviation, distended neck veins, hemodynamic compromise
Key Diagnostic Features
- Risk factors: Trauma, mechanical ventilation, COPD, tall thin body habitus
- Requires immediate needle decompression if unstable
- Chest X-ray confirms diagnosis but should not delay treatment in unstable patients
5. Esophageal Rupture
Clinical Presentation
- Symptoms: Severe chest pain following forceful vomiting (Boerhaave syndrome)
- Physical findings: Subcutaneous emphysema, unilateral decreased breath sounds 1
- Associated findings: Fever, sepsis, shock in later stages
Key Diagnostic Features
- Risk factors: History of forceful vomiting, instrumentation, caustic ingestion
- Hamman's sign (crunching sound with heartbeat) may be present
- Pleural effusion (often left-sided) may be present on imaging
Approach to Chest Pain Evaluation
Initial Assessment (within 5 minutes)
- Vital signs, oxygen saturation, level of consciousness
- Brief focused history: Onset, quality, radiation, associated symptoms
- 12-lead ECG within 10 minutes of arrival 1
Immediate Interventions
- Oxygen if hypoxemic
- IV access
- Aspirin 160-325mg (chewed) if ACS suspected 2
- Pain control as appropriate
Risk Stratification
- High-risk features: Hemodynamic instability, altered mental status, respiratory distress
- Consider validated risk scores (HEART, TIMI, GRACE) 2
- Serial ECGs and cardiac biomarkers if ACS suspected
Diagnostic Testing Based on Clinical Suspicion
- ACS: Serial ECGs, cardiac biomarkers
- PE: D-dimer, CT pulmonary angiogram
- Aortic dissection: CT angiogram or MRI of chest
- Pneumothorax: Chest X-ray, ultrasound
- Esophageal rupture: CT chest with oral contrast, esophagram
Common Pitfalls to Avoid
- Relying solely on ECG to rule out ACS (may be normal initially)
- Using nitroglycerin response as a diagnostic test for ACS 2
- Discharging patients with ongoing symptoms
- Underdiagnosing women and elderly patients who may present atypically 2
- Failing to consider multiple diagnoses simultaneously (e.g., PE in a patient with known CAD)
- Delaying treatment while awaiting confirmatory tests in unstable patients
Special Considerations
- Elderly patients often present atypically with dyspnea, syncope, or altered mental status rather than chest pain 1
- Women may present with more subtle symptoms including fatigue, dyspnea, or epigastric discomfort
- Diabetic patients may have silent ischemia due to autonomic neuropathy
- Patients with prior cardiac history may minimize symptoms or assume they are non-cardiac
Remember that these five life-threatening causes of chest pain require rapid diagnosis and treatment to reduce morbidity and mortality. A systematic approach focusing on these critical diagnoses while maintaining a broad differential is essential for optimal patient outcomes.