Which life‑threatening conditions must be excluded in a patient presenting with acute chest pain in the emergency department?

Life-Threatening Conditions to Exclude in Acute Chest Pain

In the emergency department, you must immediately exclude six life-threatening conditions: acute coronary syndrome (ACS), aortic dissection, pulmonary embolism, tension pneumothorax, esophageal rupture, and pericardial tamponade. 1, 2, 3

The "Big Six" Life-Threatening Diagnoses

1. Acute Coronary Syndrome (ACS)

• Clinical presentation: Pressure, squeezing, or heaviness in the retrosternal area building gradually over minutes, often radiating to left arm, neck, or jaw 1, 2
• Associated symptoms: Diaphoresis, tachypnea, tachycardia, hypotension, nausea, vomiting 1, 2
• Physical findings: May have crackles, S3 gallop, new mitral regurgitation murmur, or examination may be completely normal in uncomplicated cases 1
• Critical action: Obtain 12-lead ECG within 10 minutes and measure cardiac troponin immediately 1, 2

2. Aortic Dissection

• Clinical presentation: Severe, abrupt onset of tearing or ripping pain, often radiating to the back 1, 2
• Physical findings: Pulse differential between extremities (present in 30% of patients, more common in type A than type B), connective tissue disorder features (Marfan syndrome) 1
• High probability triad: Severe pain + pulse differential + widened mediastinum on chest X-ray yields >80% probability 1
• Associated findings: Syncope occurs in >10% of cases, aortic regurgitation in 40-75% of type A dissections 1

3. Pulmonary Embolism (PE)

• Clinical presentation: Sudden dyspnea and pleuritic chest pain (pain worsens with inspiration) 1, 2
• Physical findings: Tachycardia and dyspnea present in >90% of patients 1
• ECG findings: May show right ventricular strain pattern 1

4. Tension Pneumothorax

• Clinical presentation: Dyspnea and pain on inspiration 1
• Physical findings: Unilateral absence of breath sounds, tracheal deviation, hypotension 1

5. Esophageal Rupture

• Clinical presentation: History of forceful emesis preceding chest pain 1
• Physical findings: Subcutaneous emphysema, pneumothorax (in 20% of patients), unilateral decreased or absent breath sounds 1

6. Pericardial Tamponade

• Clinical presentation: Pleuritic chest pain that increases in supine position 1
• Physical findings: Fever, friction rub, signs of hemodynamic compromise 1

Mandatory Initial Actions Within 10 Minutes

The 2021 ACC/AHA guidelines mandate three immediate actions: 1, 2

1. Obtain and interpret 12-lead ECG within 10 minutes to identify STEMI or other acute ischemic changes 1, 2
2. Measure cardiac troponin as soon as possible when ACS is suspected 1
3. Assess vital signs and hemodynamic stability including heart rate, blood pressure, respiratory rate, and oxygen saturation 1, 4

Critical Physical Examination Findings

High-Risk Cardiac Features

• Hemodynamic instability: Hypotension (systolic BP <100 mmHg), tachycardia (>100 bpm), or bradycardia (<50 bpm) 1, 4
• Heart failure signs: Crackles, S3 gallop, elevated jugular venous pressure 1
• New murmurs: Mitral regurgitation (papillary muscle dysfunction), aortic regurgitation (dissection) 1

Vascular Examination

• Pulse differential: Check all four extremities for asymmetry suggesting aortic dissection 1
• Carotid pulse character: Tardus/parvus suggests aortic stenosis, rapid upstroke suggests aortic regurgitation 1

Respiratory Examination

• Unilateral breath sounds: Suggests pneumothorax or massive pleural effusion 1
• Subcutaneous emphysema: Suggests esophageal rupture or pneumomediastinum 1

Other Serious (But Not Immediately Life-Threatening) Cardiac Conditions

Structural Heart Disease

• Aortic stenosis: Characteristic systolic murmur, tardus or parvus carotid pulse 1
• Hypertrophic cardiomyopathy: Increased or displaced left ventricular impulse, prominent a wave in jugular venous pressure, systolic murmur 1
• Myocarditis: Fever, chest pain, heart failure signs, S3 gallop 1

Non-Cardiac Serious Conditions

• Pneumonia: Fever, localized chest pain (may be pleuritic), regional dullness to percussion, egophony 1
• Spontaneous pneumothorax: Dyspnea, pleuritic pain, unilateral absence of breath sounds 1

Common Pitfalls to Avoid

Do not rely on nitroglycerin response as a diagnostic tool - esophageal spasm and other non-cardiac conditions may also respond to nitroglycerin 2

Do not assume normal ECG excludes ACS - 30-40% of patients with acute myocardial infarction have normal or non-diagnostic initial ECG 1

Do not delay transfer for additional testing in office settings - patients with suspected ACS or other life-threatening causes should be transported urgently to the ED by EMS 1, 2

Do not use the term "atypical chest pain" - this terminology can lead to underestimation of risk; instead describe pain as cardiac, possibly cardiac, or non-cardiac 2

Do not assume young age excludes serious disease - ACS can occur even in adolescents without traditional risk factors 2

Do not dismiss sharp or pleuritic pain as non-cardiac - pericarditis and atypical ACS presentations can present with these characteristics 2

Special Population Considerations

Women

• More likely to present with accompanying symptoms: nausea, fatigue, dyspnea, jaw pain, neck pain, back pain 2
• Higher risk for underdiagnosis of ACS 2
• May use different pain descriptors: "tearing" more frequently, "grinding" less frequently 1

Older Adults (≥75 years)

• May present with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 2
• Higher likelihood of silent ischemia 2

Patients with Diabetes

• More likely to present with atypical symptoms including vague abdominal symptoms, confusion, or isolated dyspnea 2
• Higher risk for silent ischemia 2

Transport Decisions

Transfer by EMS is mandatory for suspected life-threatening conditions because: 1

• Prehospital ECG acquisition facilitates rapid reperfusion if STEMI is present 1
• Trained personnel can provide treatment for arrhythmias and implement defibrillation en route 1
• Shorter travel time to ED compared to personal automobile 1
• Personal automobile transport is associated with increased risk and should be avoided 1