According to Canadian guidelines, provide a one‑page chest‑pain review organized by the College of Family Physicians of Canada (CFPC) objectives.

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Last updated: February 12, 2026 • View editorial policy

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CHEST PAIN: CFPC OBJECTIVES REVIEW

1. RECOGNIZE LIFE-THREATENING PRESENTATIONS

Immediately identify six conditions that can cause death within minutes to hours: acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, cardiac tamponade, and esophageal rupture. 1, 2

Acute Coronary Syndrome (ACS)

  • Typical presentation: Retrosternal pressure, squeezing, or heaviness building over minutes (not seconds), radiating to left arm, jaw, or neck 1, 2
  • Associated symptoms: Diaphoresis, dyspnea, nausea, syncope, palpitations 1, 2
  • Critical fact: 13% of patients with sharp, pleuritic pain still have myocardial ischemia 1, 2
  • Physical exam may be completely normal in uncomplicated MI 1, 2

Aortic Dissection

  • Presentation: Sudden "ripping" or "tearing" chest/back pain, maximal at onset 1, 2
  • Key signs: Pulse differential between extremities (~30%), BP difference >20 mmHg between arms, new aortic regurgitation murmur (40-75% of type A) 1, 2
  • High-risk features: Connective tissue disorders (Marfan), hypertension, bicuspid aortic valve 2

Pulmonary Embolism

  • Presentation: Sudden dyspnea with pleuritic chest pain worsening on inspiration 1, 2
  • Physical findings: Tachycardia (>90% of patients), tachypnea (>70%) 2

Tension Pneumothorax

  • Presentation: Dyspnea, sharp inspiratory chest pain 2
  • Physical signs: Unilateral absent breath sounds, tracheal deviation, hypotension 1, 2

Cardiac Tamponade

  • Presentation: Pleuritic pain worse supine 1, 2
  • Signs: Jugular venous distension, hemodynamic compromise, friction rub 2

2. PERFORM IMMEDIATE DIAGNOSTIC EVALUATION

Obtain 12-lead ECG within 10 minutes of arrival and draw high-sensitivity cardiac troponin immediately in all patients with suspected cardiac chest pain. 1, 2, 3

ECG Interpretation

  • STEMI: ST-elevation ≥1 mm in contiguous leads → activate reperfusion protocol immediately 1, 3
  • NSTE-ACS: ST-depression, T-wave inversions → admit to CCU, dual antiplatelet therapy, urgent angiography 2, 3
  • Normal ECG does NOT exclude ACS: 30-40% of acute MI present with normal/nondiagnostic ECG 1, 2
  • If initial ECG nondiagnostic but high suspicion: Serial ECGs every 15-30 minutes, add posterior leads V7-V9 2, 3

Troponin Strategy

  • High-sensitivity troponin is the preferred biomarker for myocardial injury 1, 3
  • Repeat at 1-3 hours (high-sensitivity) or 3-6 hours (conventional assay) to improve diagnostic accuracy 2
  • Single normal troponin does NOT rule out ACS – serial measurements required 2

Focused Physical Examination

  • Vital signs: HR, BP in both arms, RR, oxygen saturation 2
  • Cardiovascular: Diaphoresis, pulse differentials, new murmurs, S3 gallop, pericardial friction rub 1, 2
  • Pulmonary: Unilateral absent breath sounds, crackles 2
  • Hemodynamic instability: SBP <100 mmHg, HR >100 or <50 bpm 2

3. OBTAIN CRITICAL HISTORY ELEMENTS

A focused history including pain characteristics, duration, associated features, and cardiovascular risk factors must be obtained. 1

Pain Characteristics That Increase ACS Likelihood

  • Quality: Pressure, squeezing, gripping, heaviness, tightness, constriction 2
  • Location & radiation: Retrosternal → left arm, neck, jaw, between shoulder blades 2
  • Onset: Gradual build over minutes, not instantaneous 2
  • Duration: Several minutes (fleeting seconds unlikely ischemic) 2
  • Precipitating factors: Exertion, emotional stress 2

Pain Features Suggesting Non-Cardiac Etiology

  • Sharp, stabbing, fleeting (<seconds) 2
  • Pleuritic (worse with inspiration) – but 13% still have ACS 1, 2
  • Positional (worse supine, better leaning forward) → pericarditis 2
  • Localized to very small area or radiation below umbilicus 2
  • Reproducible with palpation – but 7% still have ACS 2

Associated Symptoms

  • Cardiac: Dyspnea, diaphoresis, nausea/vomiting, syncope, palpitations 1, 2

Risk Factor Assessment

  • Essential factors: Age, sex, diabetes, hypertension, hyperlipidemia, smoking, family history of premature CAD 2

4. RECOGNIZE SPECIAL POPULATION PRESENTATIONS

Women

Women are at high risk for underdiagnosis of ACS and more frequently present with accompanying symptoms rather than classic chest pain. 1, 2

  • Accompanying symptoms: Nausea, fatigue, dyspnea, jaw/neck/back pain, epigastric discomfort 1, 2
  • Chest pain remains the dominant symptom in 87-92% of women with ACS 2
  • Use sex-specific hs-cTn thresholds: >16 ng/L for women vs >34 ng/L for men 2

Older Adults (≥75 years)

  • Atypical presentations: Isolated dyspnea, syncope, acute delirium, unexplained falls without classic chest pain 1, 2, 3

Patients with Diabetes

  • Higher risk for silent ischemia and atypical symptoms (vague abdominal symptoms, confusion, isolated dyspnea) 2

5. IMPLEMENT IMMEDIATE MANAGEMENT

Pre-Hospital / Office Setting

If ACS suspected, arrange urgent EMS transport immediately – do NOT delay for troponin testing in office settings. 2, 3

  • Chewed aspirin 162-325 mg unless contraindicated (allergy, active GI bleeding) 2, 3
  • Sublingual nitroglycerin unless SBP <90 mmHg or HR <50 or >100 bpm 2, 3
  • Oxygen 2-4 L/min only if breathless, heart failure features, or low oxygen saturation 2, 3
  • IV morphine 4-8 mg (repeat 2 mg q5min) for pain relief 2, 3

Emergency Department Management

STEMI Protocol

Door-to-balloon <90 minutes (primary PCI preferred) or door-to-needle <30 minutes (fibrinolysis). 2, 3

NSTE-ACS Protocol

  • Admit to CCU with continuous cardiac monitoring 2, 3
  • Dual antiplatelet therapy: Aspirin + P2Y12 inhibitor 2
  • Anticoagulation: Unfractionated heparin, enoxaparin, or fondaparinux 2
  • Plan urgent coronary angiography 2, 3

6. APPLY RISK STRATIFICATION

High-Risk Features (Immediate CCU Admission)

  • Prolonged ongoing rest pain >20 minutes 3
  • Hemodynamic instability (SBP <100, HR >100 or <50) 2, 3
  • Elevated troponin above 99th percentile 2, 3
  • ST-segment changes on ECG 3
  • Signs of heart failure (crackles, S3 gallop, new murmurs) 2, 3

Low-Risk Criteria (Chest Pain Unit Observation or Discharge)

  • Normal/nondiagnostic ECG 2
  • Negative troponin at presentation and 6-12 hours 2
  • Stable vital signs, no ongoing pain 2
  • Absence of heart failure signs 2
  • Management: Observe 10-12 hours or discharge with outpatient stress testing within 72 hours 2

Intermediate-Risk

  • Age >70 years, diabetes, prior MI/CAD, rest angina >20 minutes that resolved 2
  • Benefit most from cardiac imaging and testing 1

7. AVOID CRITICAL PITFALLS

Do NOT rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain – esophageal spasm also responds 1, 2, 4

Do NOT dismiss chest pain in women, elderly, or diabetics based on atypical presentations 2, 3

Do NOT assume normal physical exam excludes ACS – uncomplicated MI can present with completely normal exam 1, 2

Do NOT delay EMS transport for troponin testing in office settings when ACS suspected 2, 3

Avoid the term "atypical chest pain" – use "cardiac," "possibly cardiac," or "non-cardiac" instead 1, 2

Do NOT assume young age excludes ACS – can occur in adolescents without risk factors 2

Sharp, pleuritic pain does NOT exclude ACS – 13% of pleuritic presentations have myocardial ischemia 1, 2

8. UTILIZE CLINICAL DECISION PATHWAYS

Clinical decision pathways for chest pain in ED and outpatient settings should be used routinely. 1

For low-risk patients, urgent diagnostic testing for suspected CAD is not needed. 1

Engage in shared decision-making with clinically stable patients regarding testing options, radiation exposure, and costs 1, 2

9. COMMON NON-CARDIAC DIAGNOSES (After Excluding Life-Threatening Causes)

Costochondritis

  • Most common musculoskeletal cause: 43% of chest pain in primary care after cardiac exclusion 2, 4
  • Features: Tenderness over costochondral joints, pain reproducible with palpation/movement 2, 4

Pericarditis

  • Features: Sharp pleuritic pain worse supine, better leaning forward; friction rub; fever 2, 4
  • ECG: Diffuse ST-elevation with PR-depression 2

GERD/Esophagitis

  • Features: Burning retrosternal pain related to meals, relieved by antacids 4

Pneumonia

  • Features: Fever, localized pleuritic pain, dullness, egophony 2, 4

Herpes Zoster

  • Features: Dermatomal pain triggered by touch, characteristic rash 2, 4

10. KEY TAKE-HOME MESSAGES

"Chest pain" encompasses discomfort in shoulders, arms, neck, back, upper abdomen, or jaw – not just the chest itself. 1

High-sensitivity troponins are the preferred standard for establishing biomarker diagnosis of AMI. 1

Patients with acute chest pain should seek medical care immediately by calling 9-1-1. 1

Use structured risk assessment and evidence-based diagnostic protocols for all chest pain presentations. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Initial Evaluation of Chest Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Initial Management of Chest Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Differential Diagnosis for Chest Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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