Approach to Assessment of Chest Pain
The evaluation of chest pain must prioritize immediate identification of life-threatening causes through a structured algorithmic approach using ECG within 10 minutes, high-sensitivity troponins, and risk stratification pathways, while recognizing that chest pain encompasses not just chest discomfort but also pain in shoulders, arms, neck, back, upper abdomen, jaw, shortness of breath, and fatigue. 1, 2
Definition
- Chest pain includes: Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw 1
- Anginal equivalents: Shortness of breath and fatigue should be considered equivalent presentations 1
- Avoid "atypical" terminology: Use "noncardiac" when heart disease is not suspected; "atypical" is misleading and discouraged 1
Classification
Acute vs. Stable Presentation
- Acute chest pain: Requires immediate evaluation with focus on life-threatening causes 1, 2
- Stable chest pain: Allows for outpatient risk stratification and diagnostic workup 1
Risk Stratification Categories
- High risk: Requires immediate action including reperfusion for STEMI, betabloqueadores and vasodilators for suspected aortic dissection 2
- Intermediate risk: Requires echocardiography, observation unit management, stress testing or coronary CT angiography 2
- Low risk: Urgent diagnostic testing for suspected coronary artery disease is not needed 1
Differential Diagnosis
Life-Threatening Cardiac Causes
- Acute coronary syndrome: Retrosternal discomfort building gradually over minutes 3, 4
- Aortic dissection: Ripping chest pain radiating to back, especially in hypertensive patients 3, 5
- Pericarditis: Requires anti-inflammatory medications and cardiology consultation 4, 6
Life-Threatening Non-Cardiac Causes
- Pulmonary embolism: Sudden dyspnea with risk factors; uncommon in adolescents 3, 4, 7
- Pneumothorax: Sudden-onset sharp chest pain with dyspnea 4, 8, 5
- Pneumomediastinum: Requires immediate radiographic evaluation 5
- Esophageal perforation: Life-threatening requiring urgent imaging 5
Common Non-Life-Threatening Causes
- Musculoskeletal (costochondritis): Pain reproducible by palpation, common in adolescents 4, 7
- Gastroesophageal reflux disease: Burning retrosternal pain related to meals 4, 7
- Pneumonia: Fever, egophony, dullness to percussion 8, 7, 6
- Panic disorder/anxiety: Screen with two-item questionnaire; manage with reassurance and breathing exercises 4, 7
- Pleurisy: Intensely painful but prognostically benign 8
History Taking
Pain Characteristics (OPQRST Framework)
- Onset: Sudden onset concerning for aortic dissection; gradual buildup typical of angina 3
- Location and radiation: Pain radiating to back suggests aortic dissection; radiation to arms/jaw suggests cardiac ischemia 3, 4
- Quality: Pressure, squeezing, heaviness more suggestive of ischemic cardiac pain 3
- Severity: "Worst pain ever" concerning for aortic dissection in hypertensive patients 3
- Timing/Duration: Determine if pain builds gradually or occurs suddenly 3, 4
- Triggers: Exertion, emotional stress, or rest 3
- Relieving factors: Rest, nitroglycerin, position changes 3
- Pleuritic nature: Pain related to breathing characteristic of pleuritic chest diseases 8
Associated Symptoms
- Cardiac indicators: Diaphoresis, nausea, vomiting, shortness of breath 3
- Severe disease markers: Syncope/presyncope (severe cardiac disease or pulmonary embolism) 3
- Arrhythmia indicators: Palpitations 3
- Infectious causes: Fever suggests pneumonia or pericarditis 3, 4
Red Flags Requiring Immediate Action
- Ripping chest pain with radiation to back in hypertensive patients or those with known aortic disease 3
- Severe pain with diaphoresis, tachypnea, tachycardia, or hypotension 3
- New-onset left bundle branch block or ST-segment changes on ECG 3
- Pain associated with syncope, severe dyspnea, or hemodynamic instability 3
Risk Factors Assessment
- Cardiovascular risk factors: History of coronary artery disease, hypertension, diabetes, smoking, family history of premature CAD 3
- Previous cardiac events: Prior myocardial infarction, angina, revascularization procedures 3
- Aortic risk factors: Hypertension, connective tissue disorders, bicuspid aortic valve, known aortic dilation 3
Special Population Considerations
- Women: More likely to present with accompanying symptoms (nausea, vomiting, dyspnea, back/neck/jaw pain); higher risk of underdiagnosis 1, 2, 3
- Elderly (≥75 years): May present with shortness of breath, syncope, acute delirium, or unexplained fall rather than classic chest pain 2, 3
- Diabetic patients: Alert for atypical presentations due to autonomic dysfunction 3
Physical Examination (Focused)
Vital Signs
- Assess: Blood pressure (both arms for dissection), heart rate, respiratory rate, oxygen saturation 3
Cardiovascular Examination
- Heart sounds: Assess for murmurs, rubs, gallops 3
- Signs of heart failure: Jugular venous distension, peripheral edema 3
- Pulse differentials: Between extremities (suggests aortic dissection) 3
Chest Wall Examination
Pulmonary Examination
- Auscultation: Egophony, dullness to percussion (suggests pneumonia) 7
Investigations and Expected Findings
Immediate Testing (Within 10 Minutes)
- 12-lead ECG: Required within 10 minutes of arrival for acute chest pain 2
- Expected findings: ST-segment elevation (STEMI), ST-depression/T-wave inversion (NSTEMI/unstable angina), new LBBB 3
Laboratory Testing
- High-sensitivity cardiac troponins: Preferred standard for biomarker diagnosis of acute myocardial infarction 1
- Expected findings: Elevated in myocardial injury/infarction 1
- D-dimer assay: Helps determine need for further pulmonary embolism evaluation 7
- Brain natriuretic peptide: Clarifies heart failure diagnosis 7
Imaging Studies
- Chest radiograph: Most patients should have this performed 7, 5
- Expected findings: Pneumonia (infiltrates), pneumothorax (absent lung markings), heart failure (pulmonary edema) 7
- Echocardiography: For intermediate-risk patients in observation unit 2
- Coronary CT angiography: For intermediate-risk patients to exclude coronary disease 2
- Cardiac stress testing: For patients with predictably exertional chest pain, ECG abnormalities, or cardiac risk factors 2, 7
Risk Stratification Tools
- Clinical decision pathways: Should be used routinely in emergency department and outpatient settings 1
- Pulmonary embolism prediction rule: Simple tool to determine risk 7
Empiric Treatment
High-Risk Acute Presentations
- Suspected STEMI: Immediate reperfusion therapy 2
- Suspected aortic dissection: Betabloqueadores and vasodilators 2
- Suspected ACS: Aspirin, antiplatelet therapy, anticoagulation per protocol 2
Specific Diagnoses
- Pericarditis: Anti-inflammatory medications 4
- Anxiety-related chest pain: Reassurance and breathing exercises 4
- Musculoskeletal pain: Analgesics, reassurance 4
Indications to Refer
Immediate Referral/Activation
- Call 9-1-1: Patients with acute chest pain or chest pain equivalent symptoms should seek immediate medical care 1
- Cardiology consultation: Suspected cardiac etiologies including pericarditis, myocarditis 4
Outpatient Referral
- Cognitive-behavioral therapy: Recurrent anxiety-related chest pain episodes 4
- Primary care follow-up: Musculoskeletal or idiopathic chest pain 4
Shared Decision-Making
- Clinically stable patients: Should be included in decision-making with information about risk of adverse events, radiation exposure, costs, and alternative options 1
Critical Pitfalls to Avoid
Diagnostic Errors
- Delayed ECG interpretation: ECG must be obtained and interpreted within 10 minutes 2, 3
- Relying on nitroglycerin response: Not reliable for diagnosis 2
- Relying solely on pain intensity: Not predictive of seriousness of underlying condition 3
- Premature diagnostic closure: Avoid anchoring on initial impression 3
Population-Specific Pitfalls
- Underdiagnosis in women: Women are at higher risk for underdiagnosis; always evaluate for potential cardiac causes 2, 3
- Dismissing atypical presentations in elderly: May present with shortness of breath, confusion, or falls rather than classic chest pain 2, 3
- Ignoring atypical presentations in diabetics: Autonomic dysfunction causes atypical symptoms 3