What is the appropriate evaluation and management of a patient presenting with chest pain?

Chest Pain Characterization: Clinical Descriptors by Diagnosis

When evaluating chest pain, the specific characteristics of onset, location, duration, quality, aggravating/alleviating factors, radiation, and timing are critical for distinguishing life-threatening conditions from benign causes, with acute coronary syndrome presenting as retrosternal pressure building gradually over minutes, radiating to the left arm/jaw/neck, while aortic dissection manifests as sudden-onset tearing pain radiating to the back. 1, 2

Life-Threatening Presentations

Acute Coronary Syndrome (ACS)

• Onset: Gradual build over minutes (not seconds), may occur at rest or with minimal exertion 1, 3
• Location: Retrosternal, substernal, or diffuse across anterior chest 2, 3
• Duration: Typically >10 minutes; unstable angina may be crescendo pattern with increasing frequency/severity 1
• Character/Quality: Pressure, heaviness, squeezing, tightness, or "elephant sitting on chest"—not sharp or stabbing 2, 3
• Aggravating Factors: Physical exertion, emotional stress, cold exposure, heavy meals 2, 4
• Alleviating Factors: Rest may relieve stable angina but not ACS; nitroglycerin response should NOT be used diagnostically as esophageal spasm also responds 2, 3
• Radiation: Left arm (most common), jaw, neck, both arms, epigastrium, or between shoulder blades 1, 2
• Associated Symptoms: Diaphoresis, dyspnea, nausea, lightheadedness, syncope 1, 2
• Critical Pitfall: Women and elderly (≥75 years) may present with isolated dyspnea, nausea, fatigue, syncope, acute delirium, or unexplained falls without classic chest pain 1, 2, 3

Aortic Dissection

• Onset: Sudden, abrupt, maximal intensity at onset (not gradual) 1
• Location: Anterior chest (type A) or interscapular region (type B) 1, 3
• Duration: Persistent, unrelenting 1, 3
• Character/Quality: Tearing, ripping, sharp, or "worst pain of my life" 1, 2, 3
• Aggravating Factors: None specific; pain does not vary with position or breathing 1
• Alleviating Factors: None; unresponsive to typical analgesics 1
• Radiation: Migrates from anterior chest to back as dissection extends; may radiate to abdomen or lower extremities 1, 3
• Physical Findings: Pulse differential between extremities (30% of patients), blood pressure differential >20 mmHg, new aortic regurgitation murmur 1, 3

Pulmonary Embolism (PE)

• Onset: Sudden, acute 1, 3
• Location: Lateral chest wall, may be unilateral 1, 5
• Duration: Persistent while embolus present 1
• Character/Quality: Sharp, pleuritic (worse with inspiration) 1, 2, 5
• Aggravating Factors: Deep inspiration, coughing 1, 5
• Alleviating Factors: Shallow breathing 5
• Radiation: May not radiate 1
• Associated Symptoms: Dyspnea (>90% of patients), tachycardia (>90%), tachypnea, hemoptysis 1, 5

Tension Pneumothorax

• Onset: Sudden 1
• Location: Unilateral chest 1
• Duration: Persistent and worsening 1
• Character/Quality: Sharp, pleuritic 1, 5
• Aggravating Factors: Inspiration 1, 5
• Alleviating Factors: None 1
• Radiation: May radiate to ipsilateral shoulder 5
• Physical Findings: Severe dyspnea, unilateral absence of breath sounds, hyperresonant percussion, tracheal deviation (late finding) 1, 5

Esophageal Rupture (Boerhaave Syndrome)

• Onset: Sudden, typically after forceful vomiting 1
• Location: Retrosternal or epigastric 1
• Duration: Persistent, progressive 1
• Character/Quality: Severe, sharp 1
• Physical Findings: Subcutaneous emphysema (crepitus), pneumothorax (20% of patients), unilateral decreased breath sounds 1

Serious Cardiac Causes (Non-ACS)

Pericarditis

• Onset: Gradual or subacute 1
• Location: Precordial, retrosternal 1, 5
• Duration: Hours to days 1
• Character/Quality: Sharp, stabbing, pleuritic 1, 5
• Aggravating Factors: Lying supine, deep inspiration, coughing 1, 5
• Alleviating Factors: Sitting up and leaning forward 1, 5
• Radiation: May radiate to trapezius ridge (pathognomonic when present) 5
• Associated Symptoms: Fever, friction rub (may be transient) 1
• ECG Findings: Widespread ST-elevation with PR depression 1, 5

Myocarditis

• Onset: Subacute 1
• Location: Precordial 1
• Duration: Persistent 1
• Character/Quality: Variable; may mimic ACS 1
• Associated Symptoms: Fever, heart failure signs, S3 gallop 1, 5

Valvular Disease

• Aortic Stenosis: Exertional chest pain with characteristic systolic murmur, tardus/parvus carotid pulse 1
• Aortic Regurgitation: Diastolic murmur at right sternal border, rapid carotid upstroke 1
• Hypertrophic Cardiomyopathy: Increased/displaced left ventricular impulse, prominent a wave in jugular venous pressure, systolic murmur that increases with Valsalva 1

Common Pulmonary Causes

Pneumonia

• Onset: Gradual over hours to days 1
• Location: Localized to affected lung region 1
• Duration: Days 1
• Character/Quality: Sharp, pleuritic 1, 5
• Aggravating Factors: Deep inspiration, coughing 1, 5
• Associated Symptoms: Fever, productive cough, regional dullness to percussion, egophony, possible friction rub 1, 5

Spontaneous Pneumothorax

• Onset: Sudden 1
• Location: Unilateral 1
• Character/Quality: Sharp, pleuritic 1, 5
• Aggravating Factors: Inspiration 1, 5
• Physical Findings: Dyspnea, unilateral absence of breath sounds, hyperresonant percussion 1, 5

Gastrointestinal Causes

Gastroesophageal Reflux Disease (GERD)/Esophagitis

• Onset: Gradual, often postprandial 3
• Location: Retrosternal, epigastric 3
• Duration: Minutes to hours 3
• Character/Quality: Burning, may mimic cardiac pain 3, 4
• Aggravating Factors: Lying down after meals, large meals, acidic/spicy foods 3
• Alleviating Factors: Antacids, upright position 3
• Radiation: May radiate to throat 3
• Critical Pitfall: Nitroglycerin may relieve esophageal spasm, so response does NOT confirm cardiac etiology 2, 3, 5

Peptic Ulcer Disease/Gallbladder Disease

• Location: Epigastric (PUD) or right upper quadrant (gallbladder) 1
• Physical Findings: Epigastric tenderness, Murphy sign (gallbladder) 1

Musculoskeletal Causes

Costochondritis/Tietze Syndrome

• Onset: Variable; may be acute or chronic 1, 3
• Location: Costochondral junctions, typically multiple sites 1, 3
• Duration: Seconds to minutes with movement; may be chronic 3
• Character/Quality: Sharp, stabbing 3
• Aggravating Factors: Palpation, breathing, turning, twisting, bending, arm movement 1, 3, 5
• Physical Findings: Reproducible tenderness of costochondral joints on palpation 1, 3
• Critical Pitfall: 7% of patients with reproducible chest wall tenderness still have ACS—do not assume benign based on palpation alone 3, 5

Chest Wall Pain (Muscle Strain)

• Location: Localized to very limited area 3
• Character/Quality: Sharp, aching 3
• Aggravating Factors: Specific movements, palpation 3

Other Causes

Herpes Zoster

• Onset: Gradual, may precede rash by days 1
• Location: Dermatomal distribution, unilateral 1, 5
• Character/Quality: Burning, stabbing, triggered by touch 1, 5
• Physical Findings: Characteristic unilateral dermatomal rash (may appear after pain onset) 1, 5

Mandatory Initial Actions

An ECG must be obtained and interpreted within 10 minutes of arrival for ANY patient with acute chest pain, regardless of setting. 1, 2 If unavailable in office setting, immediate transfer to ED is required. 1

Cardiac troponin should be measured as soon as possible in all ED patients with acute chest pain and suspected ACS. 1, 2 Do NOT delay transfer from office to ED for troponin testing. 1, 2

Patients with clinical evidence of ACS or life-threatening causes must be transported urgently to ED by EMS, NOT personal automobile. 1, 2

Critical Terminology

The term "atypical chest pain" should be abandoned—instead use "cardiac," "possibly cardiac," or "noncardiac" as these terms are more diagnostically specific. 1 The term "atypical" is misleading and can result in dangerous underestimation of risk. 1