Approach to Chest Pain Evaluation
The evaluation of chest pain requires immediate triage to identify life-threatening conditions within 10 minutes, followed by systematic assessment of pain characteristics, cardiovascular risk factors, and targeted diagnostic testing to determine cardiac versus non-cardiac etiology. 1
Immediate Triage and Life-Threatening Conditions
Obtain a 12-lead ECG within 10 minutes of patient contact to identify ST-segment elevation myocardial infarction (STEMI), new left bundle branch block, ST-segment depression, or T-wave inversions that indicate acute coronary syndrome (ACS). 1, 2
The following conditions require immediate identification and emergency department transfer:
- Acute Coronary Syndrome: Retrosternal pressure/heaviness/squeezing building gradually over minutes, radiating to left arm/neck/jaw, with associated diaphoresis, dyspnea, nausea, or syncope 1, 3
- Aortic Dissection: Sudden-onset "ripping" or "tearing" pain radiating to back, with pulse differentials between extremities or new aortic regurgitation murmur 1, 3
- Pulmonary Embolism: Acute dyspnea with pleuritic chest pain, tachycardia (>90% of patients), and tachypnea 1, 3
- Tension Pneumothorax: Severe dyspnea with unilateral absence of breath sounds 3
- Esophageal Rupture: Severe pain with subcutaneous emphysema 1
Comprehensive History Taking
Systematically capture six key pain characteristics: nature, onset/duration, location/radiation, precipitating factors, relieving factors, and associated symptoms. 1, 4
Pain Quality and Temporal Pattern
High probability of ischemia when described as:
- Pressure, squeezing, gripping, heaviness, tightness, or constriction (rarely described as "pain" itself) 1, 4
- Central, left-sided, retrosternal location 1, 4
- Exertional or stress-related 1
- Building gradually over several minutes (not instantaneous) 1, 4
Low probability of ischemia when described as:
- Sharp, stabbing, fleeting (lasting only seconds) 1, 4
- Pleuritic (worsening with inspiration) 1, 4
- Localized to very small area or radiating below umbilicus 4
- Right-sided or shifting location 1
Critical Associated Symptoms
Document presence of:
- Dyspnea, diaphoresis, nausea/vomiting, lightheadedness, presyncope, syncope, or palpitations (commonly accompany myocardial ischemia) 1, 4
- Upper abdominal pain or heartburn unrelated to meals (may represent anginal equivalents) 4
Cardiovascular Risk Factor Assessment
Systematically assess: age, sex, smoking history, diabetes mellitus, hypertension, hyperlipidemia, family history of premature coronary artery disease, and prior history of myocardial infarction or coronary artery disease. 1, 4
Special Population Considerations
Women
Women are at high risk for underdiagnosis and must have potential cardiac causes considered in all presentations. 1 Women more commonly present with accompanying symptoms including nausea, fatigue, shortness of breath, jaw pain, neck pain, and back pain alongside or instead of classic chest pain. 1 Obtain a history that specifically emphasizes these accompanying symptoms. 1
Older Adults (≥75 years)
Consider ACS when accompanying symptoms include shortness of breath, syncope, acute delirium, or unexplained falls, even without classic chest pain. 1 These patients frequently present with atypical symptoms or isolated dyspnea rather than chest discomfort. 4
Patients with Diabetes, Renal Insufficiency, or Dementia
These populations more frequently experience atypical symptoms including sharp pain, throat/abdominal discomfort, or isolated dyspnea. 4
Physical Examination
Perform a focused cardiovascular examination immediately to identify complications and aid diagnosis of life-threatening causes. 1
Key Examination Findings by Diagnosis:
- ACS: Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, new mitral regurgitation murmur (examination may be normal in uncomplicated cases) 1
- Aortic Dissection: Pulse differential between extremities (30% of patients), blood pressure differential, new aortic regurgitation murmur 1
- Pulmonary Embolism: Tachycardia (>90% of patients), tachypnea 1
- Pericarditis: Fever, friction rub, pain worsening supine and improving when leaning forward 1
- Costochondritis: Tenderness of costochondral joints reproducible with palpation 1, 3
- Pneumothorax: Unilateral absence of breath sounds 1
Diagnostic Testing Algorithm
ECG Interpretation
If ST-elevation or new ischemic changes are present: Immediate transfer by EMS for reperfusion therapy (door-to-balloon <90 minutes for primary PCI or door-to-needle <30 minutes for fibrinolysis). 2
Cardiac Biomarkers
Measure high-sensitivity cardiac troponin (hs-cTn) as soon as possible when ACS is suspected, as it has >90% sensitivity and >95% specificity for detecting myocardial injury. 2, 5 Serial measurements are required if initial troponin is negative but clinical suspicion remains high. 2
Do NOT use total CK alone as it is neither sensitive nor specific enough to diagnose or exclude acute myocardial infarction. 2
Terminology and Risk Categorization
Avoid the term "atypical chest pain" as it is not helpful in determining cause and can be misinterpreted as benign. Instead, describe chest pain as cardiac, possibly cardiac, or noncardiac. 1, 4
Categorize patients as:
- High-risk: Prolonged ongoing rest pain, hemodynamic instability, elevated troponin above 99th percentile 2
- Intermediate-risk: Prior MI or CAD, age >70 years, diabetes mellitus, rest angina >20 minutes that has resolved 2
- Low-risk: Brief pain, no risk factors, normal ECG and troponin 6
Setting-Specific Management
Office Setting
Unless a noncardiac cause is evident, obtain an ECG; if unavailable, refer patient to ED so one can be obtained. 1 Patients with clinical evidence of ACS or other life-threatening causes must be transported urgently to the ED by EMS, not by personal automobile. 1
Emergency Department
Activate 9-1-1 for transport by EMS rather than self-transport, as this allows for intervention if complications occur en route and reduces in-hospital delay time and mortality. 1, 2
Critical Pitfalls to Avoid
Do NOT use nitroglycerin response as a diagnostic criterion for myocardial ischemia, as esophageal spasm and other conditions also respond to nitroglycerin. 1, 2
Do NOT dismiss chest pain in women or elderly patients based on atypical presentation, as they frequently present with non-classic symptoms but remain at high risk for ACS. 1
Do NOT delay transfer to ED for troponin testing in office settings when ACS is suspected. 2
Do NOT assume young age excludes ACS, as it can occur even in adolescents without traditional risk factors. 2