What is the management of chest pain due to various causes, including cardiac, pulmonary, musculoskeletal, and gastrointestinal etiologies?

Management of Chest Pain by Etiology

The management of chest pain requires immediate risk stratification with ECG within 10 minutes and cardiac monitoring for all patients, followed by cause-specific treatment pathways that prioritize life-threatening cardiac, pulmonary, and vascular emergencies before addressing benign etiologies. 1, 2

Immediate Universal Management (All Chest Pain Presentations)

Initial Stabilization

• Place patient on continuous cardiac monitoring with emergency resuscitation equipment at bedside immediately upon arrival 2
• Obtain 12-lead ECG within 10 minutes of patient contact—this is the single most critical diagnostic step 1, 2, 3
• Measure vital signs: blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature 2
• Establish intravenous access and draw blood for high-sensitivity cardiac troponin, complete blood count, and basic metabolic panel 2
• Administer supplemental oxygen only if oxygen saturation is <94% (not routinely for all patients) 2

Risk Stratification Based on Clinical Setting

The probability of cardiac causes varies dramatically by setting: 20% in general practice, 60% at dispatch centers, 69% with ambulance crews, and 45% in emergency departments 1, 3. This context determines urgency of evaluation.

Management of Life-Threatening Cardiac Causes

Acute Coronary Syndrome (ACS)

High-risk features requiring immediate intervention: recurrent ischemia with ongoing pain or dynamic ECG changes, elevated troponin, hemodynamic instability (hypotension or pulmonary edema), major arrhythmias (ventricular tachycardia/fibrillation), or ST-segment elevation/new left bundle branch block on ECG 2

Immediate Pharmacotherapy

• Aspirin 250-500 mg orally (chewed for faster absorption) unless contraindicated by allergy or active bleeding 2
• Morphine intravenously titrated to pain severity for severe pain relief 2
• Low molecular weight heparin or unfractionated heparin for anticoagulation 2
• Beta-blockers (e.g., metoprolol) if no contraindications, particularly with tachycardia or hypertension 2, 4

Reperfusion Strategy

• For ST-elevation MI: Activate cardiac catheterization laboratory immediately for primary percutaneous coronary intervention (PCI), or administer thrombolytics if PCI unavailable within 120 minutes (door-to-needle time <30 minutes) 2
• For non-ST elevation ACS with high-risk features: Plan early invasive strategy with coronary angiography within 48 hours 2

Admission Criteria

Admit to coronary care unit or intensive care unit without delay for: ongoing chest pain, ischemic ECG changes, positive troponin, left ventricular failure, or hemodynamic abnormalities 2

Aortic Dissection

• Presents with sudden onset "ripping" chest pain radiating to back, with extremity pulse differential in 30% of cases 1, 3
• Immediate CT angiography of chest/abdomen/pelvis if suspected 2
• Aggressive blood pressure control with intravenous beta-blockers (target systolic BP 100-120 mmHg, heart rate <60 bpm) before vasodilators 1
• Emergency cardiothoracic surgery consultation for Type A dissection (ascending aorta involvement)

Pericarditis

• Sharp, pleuritic pain that improves sitting forward and worsens supine, with widespread ST-elevation and PR depression on ECG 1, 3
• NSAIDs (e.g., ibuprofen 600-800 mg three times daily) plus colchicine (0.6 mg twice daily) for 3 months 1
• Avoid anticoagulation unless absolutely necessary due to risk of hemopericardium
• Echocardiography to assess for pericardial effusion and tamponade 2

Management of Life-Threatening Pulmonary Causes

Pulmonary Embolism

• Tachycardia and dyspnea present in >90% of patients, with pleuritic pain on inspiration 1, 3
• CT pulmonary angiography for definitive diagnosis 2
• Anticoagulation with low molecular weight heparin or direct oral anticoagulants immediately if high clinical suspicion (don't wait for imaging if unstable) 1
• Thrombolysis for massive PE with hemodynamic instability

Pneumothorax

• Dyspnea, pleuritic pain, unilateral absent breath sounds, and hyperresonant percussion 1, 3
• Chest X-ray for diagnosis 2
• Needle decompression for tension pneumothorax (immediate, before imaging)
• Chest tube placement for significant pneumothorax (>2 cm or symptomatic)

Management of Gastrointestinal Causes

Gastroesophageal Reflux Disease (GERD)

• Most common GI cause, accounting for 10-20% of outpatient chest pain 3
• Proton pump inhibitor trial (e.g., omeprazole 20-40 mg daily) for 4-8 weeks after cardiac causes excluded 5
• Response to PPI therapy supports diagnosis but does not definitively exclude cardiac disease

Esophageal Rupture (Boerhaave Syndrome)

• Emesis followed by severe chest pain, subcutaneous emphysema, pneumothorax in 20% 1
• Immediate CT chest with oral contrast for diagnosis 2
• Emergency surgical consultation and broad-spectrum antibiotics
• This is a surgical emergency with high mortality if delayed

Management of Musculoskeletal Causes

Costochondritis/Tietze Syndrome

• Most common cause in general practice (43%), but only 5-14% in emergency settings 1, 3
• Tenderness of costochondral joints on palpation 1, 3
• Critical caveat: Approximately 7% of patients with reproducible chest wall tenderness still have ACS—never rely on this finding alone to exclude cardiac disease 1

Treatment

• NSAIDs (e.g., ibuprofen 400-600 mg three times daily) for pain relief 6
• Manual therapy and transcutaneous electrical nerve stimulation for functional myofascial disorders 6
• Stabilization exercises for chronic cases 6

Management of Psychiatric Causes

Panic Disorder/Anxiety

• Accounts for 5-11% of chest pain presentations 1, 3
• Diagnosis of exclusion after cardiac causes ruled out with serial troponins and stress testing
• Cognitive behavioral therapy as first-line treatment
• SSRIs or benzodiazepines for severe cases, but only after comprehensive cardiac evaluation

Critical Pitfalls to Avoid

Do Not Rely on Pain Severity

Pain severity is a poor predictor of imminent complications such as cardiac arrest—mild discomfort can represent massive MI 2, 3

Do Not Delay Treatment for Definitive Diagnosis

In patients with red flags (diaphoresis, radiation to jaw/arm, ST-segment changes), initiate treatment immediately while pursuing diagnosis 2

Do Not Discharge Based on Normal Initial ECG Alone

Serial troponin measurements at 0,3, and 6-12 hours are required to exclude ACS, as initial troponin is normal in 30-50% of patients with MI 2, 3

Do Not Transport High-Risk Patients by Private Vehicle

Approximately 1 in 300 chest pain patients transported by private vehicle experiences cardiac arrest en route—activate 9-1-1 for emergency medical services transport 1, 2

Recognize Atypical Presentations

Elderly patients and those with diabetes may present with atypical symptoms (dyspnea, fatigue, nausea) without classic chest pain 2

Do Not Assume Reproducible Chest Wall Tenderness Excludes ACS

Up to 7% of patients with chest wall tenderness on palpation still have acute coronary syndrome 1