What indicates that chest pain is a serious condition?

Recognizing Serious Chest Pain

Chest pain requires immediate medical attention when it interrupts normal activity or is accompanied by cold sweat, nausea, vomiting, fainting, or anxiety/fear, as these are red flags indicating potentially life-threatening conditions. 1

Red Flags Indicating Serious Chest Pain

• Severe, prolonged chest pain of acute onset is a red flag requiring immediate hospital care regardless of the cause 2, 1
• Pain that interrupts normal activities should be considered serious 1, 3
• Accompanying symptoms that indicate severity include:
  • Cold sweat, nausea, vomiting 1, 3
  • Fainting or lightheadedness 1, 3
  • Anxiety or fear 1
• Chest pain radiating to the arm, jaw, neck, or back may indicate cardiac origin 2, 3
• Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, or murmur may indicate emergency ACS 2

Characteristics of Serious Cardiac Chest Pain

• Anginal symptoms typically present as retrosternal chest discomfort (pain, heaviness, tightness, pressure, constriction, squeezing) 2
• Gradual build in intensity over several minutes (not sudden or fleeting) 2
• Often precipitated by physical or emotional stress, or occurring at rest in ACS 2
• Pain occurring at rest or with minimal exertion suggests unstable angina 2
• Women may experience different symptoms than men, including more frequent pain in the back, neck, and jaw 3

Characteristics of Non-Cardiac or Less Serious Chest Pain

• Pain that varies with respiration, body position, or food intake 2
• Well-localized pain on the chest wall accompanied by local tenderness 2
• Sharp chest pain that increases with inspiration and lying supine (suggests pericarditis rather than ischemia) 2
• Pain that can be localized to a very limited area or radiating below the umbilicus 2
• Fleeting chest pain lasting only seconds is unlikely related to ischemic heart disease 2

Other Potentially Serious Causes of Chest Pain

• Aortic dissection: Sudden onset of ripping chest pain ("worst pain of my life"), especially in hypertensive patients or those with known bicuspid aortic valve or aortic dilation 2
• Pulmonary embolism: Often presents with tachycardia, dyspnea, and pain with inspiration 2
• Pneumothorax: May present with pleuritic chest pain and unilateral absence of breath sounds 2
• Esophageal rupture: Chest pain accompanied by a painful, tympanic abdomen 2

Immediate Actions When Serious Chest Pain is Suspected

• Call 9-1-1 immediately to activate emergency medical services 2, 1
• Take a fast-acting aspirin tablet (250-500mg) if not contraindicated 2, 3
• Do not wait for symptoms to disappear as they are poor indicators of risk 2, 1
• Avoid private vehicle transport as approximately 1 in 300 chest pain patients transported by private vehicle goes into cardiac arrest en route 1

Important Pitfalls to Avoid

• Do not rely solely on pain severity to determine urgency, as severity is a poor predictor of imminent complications such as cardiac arrest 1
• Do not delay treatment while waiting for definitive diagnosis in patients with red flags 1
• Do not dismiss atypical presentations in women, elderly patients, or those with diabetes 1, 3
• Do not assume chest wall tenderness rules out serious conditions, although it reduces the probability of ACS 2

Remember that approximately half of chest pain cases are of cardiac origin, while the other half are due to non-cardiac causes, primarily esophageal disorders 4. The priority is to rapidly identify and treat life-threatening conditions while also addressing patient anxiety, which can exacerbate symptoms 4.