What are the key questions to ask a patient experiencing chest pain?

Key Questions to Ask a Patient Experiencing Chest Pain

When evaluating chest pain, immediately focus on identifying life-threatening causes through systematic questioning about pain characteristics, timing, associated symptoms, and risk factors, as this approach determines whether urgent transfer to the emergency department is required. 1

Essential Pain Characteristics

Location and Radiation Pattern

• Ask about the exact location of pain and where it radiates 1, 2
  • Retrosternal pressure radiating to left arm, jaw, or neck suggests acute coronary syndrome 2
  • Pain radiating to the back, particularly "ripping" or "tearing" quality, raises concern for aortic dissection 3, 2
  • Remember that chest pain encompasses discomfort in shoulders, arms, neck, back, upper abdomen, or jaw—not just the chest itself 1

Quality and Character of Pain

• Determine if the pain is pressure, squeezing, sharp, pleuritic, or burning 1, 2
  • Pressure or squeezing quality building gradually over minutes suggests myocardial ischemia 2
  • Sharp, pleuritic pain worsening with inspiration indicates pleural involvement (pneumothorax, pulmonary embolism, pericarditis, pneumonia) 3, 4
  • Sharp pain that improves sitting forward and worsens supine suggests pericarditis 1, 3
  • Burning retrosternal pain related to meals suggests esophageal causes 2

Temporal Features

• Ask about onset (sudden versus gradual), duration, and pattern 5, 2
  • Sudden-onset pain suggests pulmonary embolism, pneumothorax, or aortic dissection 3, 2
  • Pain building gradually over minutes is characteristic of acute coronary syndrome 2
  • Fleeting pain lasting only seconds makes cardiac ischemia unlikely 2

Critical Associated Symptoms

Cardiovascular Red Flags

• Inquire about diaphoresis, dyspnea, nausea, syncope, or palpitations 2
  • These accompanying symptoms significantly increase likelihood of acute coronary syndrome 1, 2
  • Women may be more likely to present with nausea and shortness of breath alongside chest pain 1
  • Syncope with chest pain raises concern for life-threatening causes 2

Respiratory Symptoms

• Ask about dyspnea, cough, and relationship to breathing 3, 4
  • Dyspnea with pleuritic pain and tachycardia suggests pulmonary embolism (present in >90% of cases) 3, 2
  • Pain on inspiration with unilateral absent breath sounds indicates pneumothorax 1, 3
  • Productive cough with fever suggests pneumonia 1, 3

Systemic Symptoms

• Question about fever, which accompanies pericarditis, myocarditis, and pneumonia 1, 3

Modifying Factors

Aggravating Factors

• Determine what makes the pain worse 5, 2
  • Pain precipitated by exertion or emotional stress suggests coronary artery disease 2
  • Pain worsening with inspiration indicates pleuritic causes 3, 4
  • Pain worsening when supine suggests pericarditis 1, 3
  • Pain reproduced by palpation, breathing, turning, or twisting suggests musculoskeletal causes 2

Relieving Factors

• Ask what alleviates the pain, but avoid using nitroglycerin response as a diagnostic criterion 2
  • Pain improving when sitting forward suggests pericarditis 3, 2
  • Pain relieved by antacids suggests gastroesophageal causes 2
  • Critical pitfall: Nitroglycerin response does not confirm or exclude myocardial ischemia, as esophageal spasm also responds to nitroglycerin 2, 6

Risk Stratification Questions

Cardiac Risk Factors

• Assess age, diabetes, hypertension, hyperlipidemia, smoking, family history of premature coronary disease, and known coronary artery disease 2, 7
  • Age >75 years with accompanying dyspnea, syncope, or delirium requires immediate attention 2
  • Diabetes, renal insufficiency, or dementia increase risk of atypical presentations 2

Past Medical History

• Ask about prior myocardial infarction, coronary interventions, heart failure, valvular disease, or arrhythmias 5, 7
  • Known cardiac conditions significantly alter pretest probability 5

Family History

• Inquire about sudden cardiac death or premature coronary disease in first-degree relatives 5

Medication History

• Document current medications, particularly anticoagulants, antiplatelet agents, and erectile dysfunction drugs 1
  • Use of phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil) contraindicates nitroglycerin administration 6

High-Risk Features Requiring Immediate Action

The following presentations mandate urgent transfer to the emergency department by EMS, not personal automobile 1:

• Clinical evidence of acute coronary syndrome or other life-threatening causes 1
• Hemodynamic instability 1
• Age >75 years with atypical symptoms 2
• Women or elderly patients with atypical presentations, as they frequently present without classic symptoms 2

Critical Pitfalls to Avoid

• Do not assume reproducible chest wall tenderness excludes serious pathology—7% of patients with palpable tenderness have acute coronary syndrome 3, 2
• Do not dismiss sharp, pleuritic pain as non-cardiac—13% of acute coronary syndrome patients present with pleuritic pain 3
• Do not delay transfer from office settings for troponin testing—patients with suspected acute coronary syndrome should be transported urgently to the ED by EMS 1, 3
• Do not rely on nitroglycerin response for diagnosis 2, 6