How should I evaluate chronic chest pain?

Evaluation of Chronic Chest Pain

Chronic chest pain requires a systematic approach to exclude life-threatening cardiac causes first, followed by structured evaluation of pulmonary, gastrointestinal, and musculoskeletal etiologies.

Initial Assessment & Risk Stratification

Mandatory First Steps

• Obtain a 12-lead ECG within 10 minutes to detect ischemic changes, prior infarction, left ventricular hypertrophy, or pericarditis patterns—even in chronic presentations, as up to 30–40% of acute coronary syndromes present with normal or nondiagnostic initial ECGs. 1
• Measure high-sensitivity cardiac troponin to exclude ongoing myocardial injury, particularly if symptoms have changed in character, frequency, or severity. 1
• Perform a chest radiograph to evaluate for cardiac silhouette abnormalities, pulmonary infiltrates, pleural effusion, pneumothorax, or mediastinal widening. 1

Critical History Elements

Pain Characteristics:

• Quality: Pressure, squeezing, gripping, heaviness, or tightness suggests ischemia; sharp, stabbing, or fleeting pain is less likely cardiac but does not exclude it (13% of ACS patients have pleuritic-type pain). 1, 2
• Location & Radiation: Retrosternal pain radiating to left arm, jaw, neck, or between shoulder blades increases cardiac probability; pain localized to a very small area or radiating below the umbilicus is unlikely ischemic. 1, 2
• Temporal Pattern: Gradual onset over minutes (not instantaneous) suggests angina; sudden maximal pain suggests dissection; positional pain (worse supine, better sitting forward) indicates pericarditis. 1, 2, 3
• Duration: Chronic pain lasting weeks to months with stable characteristics suggests non-cardiac causes, but accelerating or crescendo patterns mandate urgent evaluation. 2

Precipitating & Relieving Factors:

• Physical exertion or emotional stress triggering symptoms strongly suggests angina. 1
• Positional changes (worse with lying flat, better leaning forward) point to pericarditis. 1, 3
• Do NOT rely on nitroglycerin response—esophageal spasm and other non-cardiac conditions may also improve. 1, 2

Associated Symptoms:

• Dyspnea, diaphoresis, nausea, vomiting, lightheadedness, presyncope, or syncope markedly increase ACS likelihood. 1, 2
• Fever with pleuritic pain suggests pericarditis, pneumonia, or pleuritis. 1, 3

Cardiovascular Risk Assessment

Document the following risk factors:

• Age (>70 years), sex (women often present atypically), diabetes, hypertension, hyperlipidemia, smoking, family history of premature CAD, prior MI or known coronary disease. 1, 2
• Post-menopausal women have accelerated atherosclerosis and higher risk. 4

Physical Examination Priorities

• Vital signs: Bilateral blood pressures (>20 mmHg difference suggests dissection), heart rate, respiratory rate, oxygen saturation. 1, 2
• Cardiac exam: New murmurs (mitral regurgitation suggests papillary muscle dysfunction; aortic regurgitation suggests dissection), S3 gallop (heart failure), pericardial friction rub. 1
• Pulmonary exam: Unilateral decreased breath sounds (pneumothorax, effusion), crackles (pneumonia, heart failure), pleural friction rub. 1, 3
• Chest wall palpation: Reproducible tenderness suggests costochondritis, but 7% of patients with chest wall tenderness still have ACS—never exclude cardiac disease based on this alone. 2, 3
• Pulse assessment: Check all four extremities for asymmetry (dissection clue). 1, 2

Diagnostic Algorithm Based on Initial Findings

If ECG Shows Ischemic Changes or Troponin is Elevated

• Immediate cardiology referral for stress testing, coronary CT angiography, or invasive angiography depending on risk stratification (TIMI or GRACE score). 1
• Admit to monitored unit if high-risk features present: ongoing pain, hemodynamic instability, elevated troponin above 99th percentile, or heart failure signs. 1, 2

If Initial ECG & Troponin Are Normal

• Repeat high-sensitivity troponin at 1–3 hours (or 3–6 hours with conventional assay)—a single normal result does not exclude ACS. 1, 2
• Serial ECGs every 15–30 minutes if symptoms persist or change. 1
• Consider posterior leads (V7–V9) if intermediate-to-high suspicion for posterior MI. 1

Outpatient Risk Stratification for Stable Chronic Pain

Low-risk patients (normal ECG, negative serial troponins, stable vital signs, no ongoing pain, no heart failure signs) can proceed to:

• Outpatient stress testing (exercise ECG, stress echo, or nuclear imaging) within 72 hours. 1, 2
• Coronary CT angiography as an alternative anatomic test for intermediate pre-test probability. 1

Intermediate-risk patients (age >70, prior MI, diabetes, multiple risk factors) require more aggressive evaluation with functional or anatomic testing. 1, 2

Special Population Considerations

Women

• High risk for underdiagnosis—more often present with jaw/neck pain, nausea, fatigue, dyspnea, or epigastric discomfort rather than classic chest pressure. 1, 2, 4
• Use sex-specific troponin thresholds (>16 ng/L for women vs >34 ng/L for men)—this reclassifies ~30% of women with myocardial injury who would be missed. 2, 4

Older Adults (≥75 years)

• May present with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain. 1, 2

Patients with Diabetes

• More likely to have atypical symptoms (vague abdominal pain, confusion, isolated dyspnea) and silent ischemia. 2

Patients with Autoimmune Disease (e.g., SLE)

• Accelerated atherosclerosis, increased thrombotic risk (antiphospholipid antibodies), and higher prevalence of pericarditis. 4
• Consider pulmonary embolism, lupus pneumonitis, and pericardial disease in differential. 4

Alternative Diagnoses After Cardiac Exclusion

Pleuritic Pain Differential

Condition	Key Features	Diagnostic Tests
Pulmonary Embolism	Sudden dyspnea, pleuritic pain, tachycardia (>90%), risk factors (immobility, oral contraceptives, malignancy)	Wells score, age-adjusted D-dimer, CT pulmonary angiography [1,3,4]
Pneumothorax	Dyspnea, sharp pain on inspiration, unilateral absent breath sounds, hyperresonance	Chest X-ray [1,3]
Pericarditis	Sharp pain worse supine/better sitting forward, friction rub, diffuse ST-elevation with PR-depression on ECG	ECG, echocardiography, cardiac MRI if uncertain [1,3,4]
Pneumonia	Fever, productive cough, localized pain, dullness to percussion, egophony	Chest X-ray [1,3]
Costochondritis	Reproducible chest wall tenderness over costochondral joints	Clinical diagnosis (but 7% still have ACS) [1,3]

Gastrointestinal Causes

• Esophageal reflux or dysmotility: Consider if recurrent pain without cardiac or pulmonary cause, especially if meal-related or positional. 3
• Peptic ulcer disease or gallbladder disease: Right upper quadrant tenderness, Murphy sign. 1

Musculoskeletal Causes

• Costochondritis/Tietze syndrome: Tenderness of costochondral joints on palpation. 1, 3
• Herpes zoster: Dermatomal pain triggered by touch, characteristic unilateral rash. 1, 3

Critical Pitfalls to Avoid

• Never dismiss symptoms based on young age or atypical presentation—ACS can occur in adolescents and young adults without traditional risk factors. 2
• Avoid the term "atypical chest pain"—describe as "cardiac," "possibly cardiac," or "non-cardiac" to prevent misinterpretation as benign. 1, 2
• Do not delay emergency evaluation if clinical evidence suggests ACS or other life-threatening causes—arrange urgent EMS transport. 1, 2
• A normal physical examination does not exclude serious disease—uncomplicated MI and early PE can present with entirely normal findings. 1, 2
• Sharp, pleuritic pain does not rule out ACS—13% of ACS patients have pleuritic-type pain. 1, 2, 3

When to Refer to Emergency Department

Immediate EMS activation required for:

• New or accelerating chest pain with exertion or at rest
• Pain accompanied by dyspnea, diaphoresis, nausea, syncope, or presyncope
• Sudden "ripping" or "tearing" pain radiating to back (dissection)
• Hemodynamic instability (SBP <90 mmHg, HR >100 or <50 bpm)
• Respiratory distress (RR >25/min, SpO₂ <90%)
• Any concern for ACS, PE, pneumothorax, or aortic dissection 1, 2, 4

Outpatient cardiology referral appropriate for:

• Stable chronic chest pain with normal initial workup
• Low-risk patients requiring stress testing or coronary CT angiography
• Follow-up after negative emergency evaluation 1, 2