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Chest Pain

Diagnostic approach

  • ABCDE survey
  • Focused clinical evaluation
  • 12-lead ECG
  • Troponin
  • CXR
  • Red flags present: Obtain POCUS (e.g., eFAST, focused cardiac ultrasound, lung POCUS) and/or definitive imaging (e.g., CTA chest for TAA).
  • Risk stratification (e.g., HEART score for ACS , Wells score for PE ) as indicated.

Management checklist

  • IV access
  • Time-sensitive management (e.g., PCI for STEMI, management of hypertensive crisis)
  • Immediate hemodynamic support as indicated
  • Urgent specialty consult and critical care unit admission as indicated

Red flag features

  • Sudden onset
  • Exertional chest pain
  • Substernal or left-sided pain
  • Radiation to the left arm, jaw, and/or back
  • Quality of chest pain: crushing, pressure, tearing, and/or ripping
  • Associated symptoms: shortness of breath, diaphoresis, nausea, and/or vomiting
  • Vital sign abnormalities (e.g., hypoxia, hypotension)
  • Pulsus paradoxus
  • Difference of > 20 mm Hg in SBP between arms
  • New murmur
  • Chest wall crepitus
  • Distant heart sounds

Life-threatening causes

  • Acute coronary syndrome
  • Acute aortic syndromes
  • Pulmonary embolism
  • Aortic dissection
  • Tension pneumothorax
  • Cardiac tamponade
  • Esophageal rupture

Nontraumatic chest pain is one of the most common reasons that patients visit the emergency department; it is also frequently encountered in both the inpatient and outpatient settings. The differential diagnosis is broad and includes cardiac (e.g., acute coronary syndrome, pericarditis), gastrointestinal (e.g., gastritis, peptic ulcer disease), pulmonary (e.g., pulmonary embolism, tension pneumothorax), musculoskeletal (e.g., costochondritis, rib contusion), and psychiatric (e.g., generalized anxiety disorder, panic disorder) etiologies. Patients with red flag features suggestive of life-threatening causes (e.g., acute coronary syndrome, pulmonary embolism) and those who are hemodynamically unstable require immediate assessment. Once life-threatening causes have been ruled out (either by patient history, examination, or rapid diagnostics), a more thorough history and examination should be performed to narrow the differential diagnosis and guide further diagnostic workup and therapy.

For traumatic causes of chest pain, see “Blunt chest trauma” and “Penetrating chest trauma.”

The following recommendations are consistent with the 2021 American Heart Association (AHA) chest pain guidelines. [1]

Approach [1][2][3]

  • All patients
    • ABCDE survey
    • Focused clinical evaluation
    • 12-lead ECG within 10 minutes of patient arrival
    • IV access
    • Routine diagnostic studies (e.g., troponin, CXR)
    • Identify and treat the underlying cause.
  • Red flags for chest pain present: i.e., high risk of critical causes of chest pain
    • Perform POCUS (e.g., eFAST, focused cardiac ultrasound, lung POCUS). [1][4]
    • Begin time-sensitive management (e.g., activate cath lab for STEMI).
    • Obtain definitive imaging (e.g., CTA chest for TAA).
    • Consider urgent specialty consult and critical care unit admission.
  • Red flags for chest pain absent: i.e., low risk of critical causes of chest pain
    • Consider additional studies (see “Diagnostics for chest pain”).
    • Use risk stratification tools, e.g.:
      • HEART score for risk stratification for ACS (See also “Decision pathway for possible NSTE-ACS.”)
      • Wells score for PE (See also “PE diagnostics.”)
    • Consider inpatient admission if the diagnosis is uncertain or clinical suspicion of a critical cause persists.

Begin management of hemodynamic instability (e.g., shock, hypertensive emergency), signs of respiratory distress, and/or respiratory failure (e.g., hypoxia, hypercapnia) as soon as they are identified.

Red flags in chest pain [1][5]

  • Symptoms
    • Sudden onset
    • Exertional chest pain
    • Substernal or left-sided pain
    • Radiation to the left arm, jaw, and/or back
    • Quality of chest pain: crushing, pressure , tearing, and/or ripping
    • Associated symptoms: shortness of breath, diaphoresis, nausea, and/or vomiting
  • Signs
    • Vital sign abnormalities (e.g., hypoxia, hypotension)
    • Pulsus paradoxus
    • Difference of > 20 mm Hg in systolic blood pressure between arms [5]
    • New murmur
    • Chest wall crepitus
    • Distant heart sounds

Chest tightness with radiation to the left arm, jaw, and/or back that is associated with dyspnea should be considered cardiac chest pain until proven otherwise. [1]

Immediately life-threatening causes of chest pain [1]

  • Acute coronary syndrome (i.e., STEMI, NSTEMI, unstable angina)
  • Pulmonary embolism
  • Aortic dissection
  • Tension pneumothorax
  • Cardiac tamponade
  • Esophageal rupture

Cardiac

See also ”Differential diagnosis of increased troponin” and “Differential diagnosis of ST elevations on ECG.”

  • Acute coronary syndrome
  • Cardiac tamponade
  • Pericarditis
  • Myocarditis
  • Endocarditis
  • Takotsubo cardiomyopathy
  • Aortic dissection
  • Valvular disease (e.g., aortic stenosis, mitral regurgitation, aortic regurgitation)
  • Stable angina
  • Vasospastic angina
  • Hypertensive crisis
  • Heart failure exacerbation
  • Postcardiac injury syndrome
  • Postmyocardial infarction syndrome
  • Postpericardiotomy syndrome

Pulmonary

  • Pulmonary embolism
  • Tension pneumothorax
  • Pneumothorax
  • Pneumonia
  • Bronchitis
  • Asthma exacerbation
  • COPD exacerbation
  • Hemothorax
  • Pulmonary edema
  • Pleural effusion
  • Pleuritis
    • Fibrinous pleuritis
    • Rheumatoid pleuritis
    • Lupus pleuritis
  • Pulmonary sarcoidosis
  • Lung contusion
  • Pulmonary infarct
  • Lung abscess
  • Lung cancer

Musculoskeletal

  • Costochondritis
  • Chest trauma
  • Chest wall pain
  • Rib fracture
  • Rib contusion
  • Osteoarthritis of the sternoclavicular or manubriosternal joint
  • Osteoarthritis of the shoulder joints
  • Slipping rib syndrome
  • Tietze syndrome
  • Overuse myalgia
  • Thoracic outlet syndrome

Gastrointestinal

  • Esophageal perforation
  • Boerhaave syndrome
  • Mallory-Weiss syndrome
  • Gastroesophageal reflux disease
  • Acute erosive gastritis
  • Acute erosive esophagitis
  • Eosinophilic esophagitis
  • Dyspepsia
  • Peptic ulcer disease
  • Esophageal motility disorder
    • Achalasia
    • Distal esophageal spasm
    • Hypercontractile esophagus
  • Esophageal hypersensitivity
  • Sliding hiatal hernia
  • Biliary colic
  • Cholelithiasis
  • Choledocholithiasis
  • Cholecystitis
  • Acute pancreatitis
  • Acute hepatitis
  • Liver abscess
  • Fitz-Hugh-Curtis syndrome

Renal

  • Renal infarct
  • Renal capsular hematoma

Dermatological

  • Herpes zoster
  • Postherpetic neuralgia

Hematologic/Oncologic

  • Acute pain crisis
  • Acute chest syndrome
  • Malignancy
  • Malignant pleural effusion
  • Splenic infarct

Rheumatologic

  • Rheumatoid arthritis
  • SLE
  • Fibromyalgia

Psychiatric

  • Functional chest pain
  • Generalized anxiety disorder
  • Panic disorder, panic attack
  • Major depressive disorder
  • Somatic symptom disorder
  • Substance use disorders (e.g., cocaine, methamphetamines, alcohol)
  • Illness anxiety disorder

The diagnostic evaluation of undifferentiated chest pain aims to first rule out immediately life-threatening causes of chest pain and then determine the etiology, guided by the pretest probability of the diagnoses under consideration.

ECG

  • Obtain 12-lead ECG as soon as possible.
  • Evaluate for:
    • STEMI and STEMI equivalents
    • Conduction abnormalities, e.g., tachyarrhythmias, heart block
    • Findings of systemic disorders and anatomic abnormalities
  • See “Life-threatening ECG findings” for details and examples.

Perform a 12-lead ECG for all patients with new or evolving chest pain as soon as possible, e.g., for timely identification of acute coronary syndrome.

Laboratory studies

Routine investigations

Applicable to most patients with undifferentiated chest pain

  • Troponin [6]
  • CBC
  • BMP

Additional investigations

Consider ordering the following studies concurrently with routine studies based on clinical assessment and pretest probability:

  • BNP or NT-proBNP
  • D-dimer
  • Lactate
  • Preoperative studies: PT, PTT, type and screen
  • Abdominal studies: LFTs , lipase, amylase
  • Acute phase reactants: ESR, CRP , procalcitonin
  • Cultures: blood cultures, sputum cultures
  • Acute viral hepatitis panel
  • Respiratory viral panel
  • Urine toxicology screen

Imaging

Imaging is often required to confirm the diagnosis and rule out differential diagnoses. The choice of initial modality is usually based on the patient's clinical status, the pretest probability of the underlying etiology, and resource availability.

Bedside investigations

The following studies can be performed on unstable patients in most emergency settings:

  • Portable CXR (anteroposterior view)
  • POCUS [1][4]
    • Focused cardiac ultrasound
    • Lung POCUS
    • eFAST
    • Biliary POCUS
    • POCUS for suspected AAA
  • Lung ultrasound
  • Portable abdominal x-ray (upright)
  • Echocardiography (e.g., TTE, TEE)

Additional investigations

The following studies typically require the patient to be stable enough for transfer to a dedicated imaging suite:

  • CXR (posteroanterior and lateral; rib series if there is concern for rib fracture)
  • Abdominal series x-ray
  • CT chest (with IV contrast)
  • CTA chest (pulmonary embolism protocol)
  • CTA chest, abdomen, and pelvis (to evaluate the aorta)
  • Ultrasound right upper quadrant
  • Lower extremity venous ultrasound
  • V/Q scan

Cardiovascular causes of chest pain
Causes Characteristic clinical features Diagnostic findings Acute management
STEMI [7]
  • Heavy, dull, pressure/squeezing sensation
  • Substernal pain with radiation to left shoulder
  • Nausea, vomiting
  • Diaphoresis, anxiety
  • Dizziness, lightheadedness, syncope
  • Pain may improve with nitroglycerin.
  • Labs: ↑ Troponin
  • ECG: ST-segment elevation/depression, T-wave inversions, Q waves
  • TTE: hypokinesis, regional wall motion abnormalities
  • See “Acute management checklist for STEMI.”
NSTEMI/UA [8]
  • Labs: Increased or normal troponin
  • ECG: nonspecific changes, including T-wave inversions, ST-depressions
  • TTE: Regional wall motion abnormalities may be present.
  • See “Acute management checklist for NSTEMI/UA.”
Aortic dissection [9][10][11]
  • Sudden onset of severe, sharp tearing chest or abdominal pain that radiates to the back
  • Hypertension or hypotension
  • Asymmetrical blood pressure, pulse deficit
  • New diastolic murmur
  • Symptoms of myocardial ischemia
  • Syncope, neurological symptoms
  • Labs: Elevated D-dimer
  • ECG: nonspecific ST-segment changes
  • CXR: widening of the aorta
  • CTA chest, abdomen, and pelvis: intimal flap with false lumen
  • TEE: proximal aortic dissection, tamponade, aortic regurgitation
  • See “Acute management checklist for aortic dissection.”
Cardiac tamponade [12]
  • Tachypnea, dyspnea
  • Tachycardia
  • Pulsus paradoxus
  • Cardiogenic shock
  • Beck triad: hypotension, JVD, muffled heart sounds
  • ECG: low voltage, electrical alternans
  • CXR: enlarged cardiac silhouette
  • TTE: circumferential fluid layer, collapsible chambers , high EF, dilated IVC
    • Inspiration: Both ventricular and atrial septa move sharply to the left.
    • Expiration: Both ventricular and atrial septa move sharply to the right.
  • See “Acute management checklist for cardiac tamponade.”
Pericarditis [13][14]
  • Sharp, pleuritic, retrosternal chest pain
  • Exacerbated by lying down; improved by leaning forward
  • Not relieved with nitrates
  • High-pitched pericardial friction rub
  • Labs: ↑ ESR, ↑ CRP, leukocytosis, ↑ troponin [13]
  • ECG: diffuse ST-elevations without reciprocal ST-depressions, PR-segment depression, or T-wave inversions
  • CXR: normal
  • TTE: pericardial effusion may be present.
  • See “Acute management checklist for acute pericarditis.”
Heart failure exacerbation [15][16][17][18]
  • Chest pressure
  • Cough, dyspnea
  • Hypoxemia
  • Crackles, JVD, peripheral edema
  • Clinical diagnosis
  • Labs: ↑ BNP, ↑ troponin , abnormal BMP
  • CXR: diffuse opacities, Kerley B lines
  • TTE: global or focal wall abnormalities, systolic and/or diastolic dysfunction, decreased LVEF
  • See “Acute management checklist for heart failure exacerbation.”
Takotsubo cardiomyopathy [19][20]
  • History of a recent stressful event
  • Retrosternal chest pain, dyspnea, heavy, dull, pressure/squeezing sensation
  • Hypotension, cardiogenic shock
  • Most common in older women
  • Labs: ↑ Troponin, ↑ BNP
  • ECG: ST-elevations, T-wave inversions
  • TTE: decreased LVEF, regional wall motion abnormalities , apical ballooning
  • cMRI: myocardial edema, regional wall motion abnormalities
  • Coronary angiography: no acute coronary stenosis or occlusion
  • See “Acute management checklist for Takotsubo cardiomyopathy.”
Thoracic aortic aneurysm
  • Feeling of pressure in the chest
  • Thoracic back pain
  • Features of mediastinal compression or obstruction (e.g., difficulty swallowing, hoarseness)
  • If ruptured: severe chest pain, possible loss of consciousness
  • Chest x-ray: abnormal aortic contour, widened mediastinum, tracheal deviation
  • CTA chest: dilation of the aorta, possible mural thrombus, dissection, perforation, or rupture
  • See “Acute management checklist for thoracic aortic aneurysm.”

Pulmonary causes of chest pain
Causes Characteristic clinical features Diagnostic findings Acute management
Pulmonary embolism [21]
  • Pleuritic chest pain
  • Acute onset dyspnea, hypoxemia
  • Cough, hemoptysis
  • Unilateral leg swelling or history of DVT
  • Hypotension, shock (if massive PE)
  • Labs
    • Elevated D-dimer
    • ↑ Troponin, BNP
  • ECG: normal sinus rhythm (most common), sinus tachycardia, signs of right ventricular strain
  • CTA chest (pulmonary embolism protocol): pulmonary artery filling defect
  • V/Q scan: perfusion-ventilation mismatch
  • TTE: right ventricle hypokinesis with normal apical movement
  • Clinical calculators
    • Wells score
    • PERC rule
    • PESI
  • See “Acute management checklist for pulmonary embolism.”
Tension pneumothorax [22][23]
  • Severe, sharp chest pain
  • Dyspnea, hypoxemia
  • History of trauma
  • Hyperresonance on percussion, decreased breath sounds, tracheal deviation
  • Tachycardia, hypotension
  • Clinical diagnosis
  • CXR: absent lung markings, tracheal deviation, pneumomediastinum
  • See “Acute management checklist for tension pneumothorax.”
Pneumonia [24]
  • Fever, chills
  • Cough, dyspnea
  • Hypoxemia
  • Crackles, egophony
  • Labs: leukocytosis, ↑ ESR/CRP, ↑ procalcitonin
  • Positive sputum culture
  • CXR: consolidation, pleural effusion
  • CT chest: hyperdense consolidation
  • See “Acute management checklist for pneumonia.”
Spontaneous pneumothorax [22][25][26]
  • Sudden, sharp unilateral chest pain
  • Acute dyspnea
  • Hypoxemia
  • Hyperresonance on percussion, decreased breath sounds on the affected side
  • Crepitus
  • History of lung disease or trauma
  • Inspiratory CXR: increased lucency, displaced lung markings, subcutaneous emphysema
  • POCUS: absent lung sliding on eFAST or lung POCUS
  • See “Acute management checklist for spontaneous pneumothorax.”
Asthma exacerbation [27]
  • Dyspnea, cough
  • Tachycardia
  • Tachypnea, hypoxemia
  • Diffuse wheezing
  • Decreased or absent breath sounds
  • Increased work of breathing
  • Peak expiratory flow: decreased from predicted or personal best
  • ABG: ↓ pH, ↑ PaCO2, ↓ PaO2 (respiratory acidosis)
  • See “Acute management checklist for asthma exacerbation.”
COPD exacerbation [28][29]
  • Dyspnea, cough
  • Purulent sputum
  • Tachypnea, hypoxemia
  • Diffuse wheezing, decreased breath sounds
  • Increased work of breathing
  • Signs of imminent respiratory arrest: confusion, absent breath sounds, bradycardia
  • ABG: ↓ pH, ↑ PaCO2, ↓ PaO2 (respiratory acidosis)
  • Labs: ↑ CRP,↑ Procalcitonin (if underlying bacterial infection)
  • CXR: hyperinflated lungs; signs of pneumonia, pneumothorax, and/or pleural effusion may be present
  • See “Acute management checklist for COPD exacerbation.”
Pleural effusion [30][31]
  • Unilateral, pleuritic chest pain
  • Dyspnea
  • Dry, nonproductive cough
  • Dullness to percussion, decreased breath sounds, decreased tactile fremitus
  • Pleural friction rub
  • CXR: homogeneous opacity with blunting of the costophrenic angle
  • Lung POCUS: hypoechoic space between the parietal and visceral pleura
  • See “Acute management checklist for pleural effusion.”

Gastrointestinal causes of chest pain
Causes Characteristic clinical features Diagnostic findings Acute management
Esophageal perforation [32][33]
  • Retrosternal chest pain, neck pain, epigastric pain with radiation to the back
  • Dyspnea, tachypnea, tachycardia
  • Dysphagia
  • Signs of sepsis
  • Mackler triad (chest pain, vomiting, subcutaneous emphysema)
  • Mediastinal crepitus
  • History of recent endoscopy or severe emesis (Boerhaave syndrome)
  • CXR, upright AXR: mediastinal air and/or subdiaphragmatic air, pleural effusion, pneumothorax
  • Lateral neck x-ray: subcutaneous emphysema
  • Contrast esophagography (gold standard): contrast leak [34]
  • CT chest (with oral contrast) : extraluminal air, esophageal thickening
  • See “Acute management checklist for esophageal perforation.”
GERD and erosive esophagitis [35][36]
  • Postprandial substernal chest pain, pressure, burning, reflux symptoms
  • Aggravated by lying in the supine position and certain foods (e.g., coffee, spices)
  • Epigastric tenderness
  • Clinical diagnosis
  • Definitive diagnosis requires EGD and/or 24-hour esophageal pH monitoring
  • See “Management of GERD.”
Gastritis [37]
  • Dyspepsia
  • Postprandial fullness
  • Epigastric tenderness
  • Clinical diagnosis
  • Follow the test-and-treat strategy for Helicobacter pylori in most patients with upper GI symptoms.
  • Consider EGD with biopsies in selected cases (e.g., patients aged > 60 years).
  • Antacids and acid reducers
  • H. pylori eradication therapy
  • See “Treatment of gastritis.”
Peptic ulcer disease [38][39][40]
  • Epigastric pain
  • Duodenal ulcer: pain relieved with food, weight gain
  • Gastric ulcer: pain exacerbated by food, weight loss
  • Signs of GI bleed
  • History of frequent NSAID use
  • Labs: ↓ Hb, ↓ Hct, ↓ RBC count, positive FOBT or melena (in patients with a bleeding ulcer)
  • Urea breath test for H. pylori: positive in most cases of PUD
  • EGD: mucosal erosions and/or ulcers
  • See “Acute management checklist for PUD.”
Acute pancreatitis [41][42][43]
  • Severe epigastric pain that radiates to the back
  • Nausea, vomiting
  • Epigastric tenderness, guarding, rigidity
  • Upper abdominal pain
  • Hypoactive bowel sounds
  • History of gallstones or alcohol use
  • Labs: ↑ Lipase, ↑ amylase
  • Abdominal ultrasound: pancreatic edema, peripancreatic fluid, gallstones
  • Abdominal CT with IV contrast : pancreatic edema, peripancreatic fat stranding, gallstones
  • See “Acute management checklist for acute pancreatitis.”
Esophageal hypermotility disorders [44][45][46][47]
  • Episodic retrosternal chest pain
  • Intermittent dysphagia, globus sensation
  • Reflux symptoms
  • Symptoms aggravated by stress and/or hot and cold food and drink
  • Upper GI endoscopy: typically normal
  • Barium swallow: normal or corkscrew esophagus appearance
  • Esophageal manometry: premature and/or hypertensive esophageal contractions
  • See “Acute management checklist for esophageal hypermotility disorders.”
Mallory-Weiss syndrome [48][49]
  • Epigastric pain that radiates to the back
  • Repeated episodes of severe vomiting
  • Hematemesis
  • Melena, dizziness, syncope
  • CBC: anemia
  • EGD: longitudinal mucosal tears, typically at the gastroesophageal junction
  • See “Acute management checklist for Mallory-Weiss syndrome.”

Noncardiac chest pain is most commonly caused by gastrointestinal and musculoskeletal disorders. [50]

Herpes zoster [51][52]

  • Clinical features
    • Severe burning or throbbing pain
    • Thoracic dermatomes are most commonly affected
    • Maculopapular rash that develops into a vesicular rash in a dermatomal distribution
    • Immunocompromised status
  • Diagnostics
    • Clinical diagnosis
    • PCR of vesicle fluid positive for varicella-zoster virus DNA [52]
  • Treatment
    • Antivirals (See the acute management checklist for herpes zoster.)
  • One-Minute Telegram 51-2022-1/3: Is all chest pain created equal?

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