What is important to ask in a patient with sudden chest pain?

Key Elements to Assess in a Patient with Sudden Chest Pain

When evaluating a patient with sudden chest pain, a focused history that includes characteristics and duration of symptoms relative to presentation, associated features, and cardiovascular risk factor assessment should be obtained to identify potentially life-threatening conditions.1

Chest Pain Characteristics

• Nature: Ask about the quality of pain (pressure, heaviness, tightness, squeezing, sharp, stabbing, burning, ripping) - descriptors like pressure, squeezing, and heaviness are more suggestive of ischemic cardiac pain 1
• Onset and duration: Determine if pain builds gradually (typical of angina) or sudden onset (concerning for aortic dissection); note that fleeting pain lasting only seconds is unlikely to be cardiac 1
• Location and radiation: Identify the location (retrosternal, left-sided, right-sided) and any radiation (to arms, jaw, back, neck) - pain radiating to the back may suggest aortic dissection 1, 2
• Severity: Ask if this is the "worst pain ever" (concerning for aortic dissection, especially in hypertensive patients) 1, 2
• Precipitating factors: Determine if pain is triggered by exertion, emotional stress, or occurs at rest 1
• Relieving factors: Ask if rest, nitroglycerin, or position changes affect the pain 1

Associated Symptoms

• Diaphoresis, nausea, vomiting: These autonomic symptoms often accompany cardiac chest pain 1
• Shortness of breath: Important associated symptom, especially in elderly patients 1
• Syncope or presyncope: May indicate severe cardiac disease or pulmonary embolism 1
• Palpitations: May suggest arrhythmia as a cause 1
• Fever: May indicate infectious causes like pneumonia or pericarditis 1

Special Considerations for Different Patient Populations

• Women: Ask about accompanying symptoms that are more common in women with ACS (nausea, vomiting, dyspnea, back/neck/jaw pain) 1
• Elderly patients (≥75 years): Consider ACS when accompanying symptoms such as shortness of breath, syncope, acute delirium are present, or when an unexplained fall has occurred 1
• Diabetic patients: Be alert for atypical presentations due to autonomic dysfunction 1, 2

Risk Factors Assessment

• Cardiovascular risk factors: History of coronary artery disease, hypertension, diabetes, smoking, family history of premature CAD 1
• Previous cardiac events: Prior myocardial infarction, angina, or revascularization procedures 1
• Aortic risk factors: History of hypertension, connective tissue disorders, bicuspid aortic valve, or known aortic dilation 1, 2

Physical Examination Focus Points

• Vital signs: Blood pressure (including comparison between arms for possible aortic dissection), heart rate, respiratory rate, oxygen saturation 1
• Cardiovascular examination: Heart sounds (murmurs, gallops, rubs), signs of heart failure (crackles, S3) 1
• Chest wall tenderness: Reproducible pain with palpation may suggest musculoskeletal causes 1, 3
• Pulse differentials: Between extremities (present in 30% of aortic dissections) 1, 2

Red Flags Requiring Immediate Action

• Ripping chest pain with radiation to the back, especially in hypertensive patients or those with known aortic disease 1, 2
• Severe pain with diaphoresis, tachypnea, tachycardia, or hypotension 1
• New-onset left bundle branch block or ST-segment changes on ECG 1, 3
• Pain associated with syncope, severe dyspnea, or hemodynamic instability 1

Common Pitfalls to Avoid

• Underdiagnosing women: Women are at higher risk for underdiagnosis and should always be evaluated for potential cardiac causes 1
• Dismissing atypical presentations in elderly: Older patients may present with shortness of breath, confusion, or falls rather than classic chest pain 1
• Relying solely on pain intensity: The severity of symptoms does not reliably predict the seriousness of the underlying condition 1
• Delayed ECG: An ECG should be obtained and reviewed within 10 minutes of arrival for all patients with acute chest pain 1, 2
• Premature diagnostic closure: Consider multiple potential life-threatening causes including ACS, aortic dissection, pulmonary embolism, and pneumothorax 1