Acute chest pain

See Acute coronary syndrome (main) for ACS-specific workup and risk stratification; see Chest pain (peds) for pediatric patients.

Background

• Chest pain accounts for approximately 6-8% of all ED visits
• The primary ED goal is to rapidly identify and treat immediately life-threatening causes ("the big 5"):
  • Acute coronary syndrome (ACS)
  • Pulmonary embolism (PE)
  • Aortic dissection
  • Tension pneumothorax
  • Esophageal perforation (Boerhaave syndrome)
• Most chest pain in the ED is ultimately non-cardiac, but the evaluation is driven by the need to exclude dangerous etiologies

Clinical Features

Risk of Acute Coronary Syndrome

Clinical factors that increase likelihood of ACS/AMI:

• Chest pain radiating to both arms > R arm > L arm
• Chest pain associated with diaphoresis
• Chest pain associated with nausea OR vomiting
• Chest pain with exertion that is improved with rest

Clinical factors that decrease likelihood of ACS/AMI:

• Pleuritic chest pain
• Positional chest pain
• Sharp, stabbing chest pain
• Chest pain reproducible with palpation

Gender differences in ACS

• Women with ACS:
  • Less likely to be treated with guideline-directed medical therapies
  • Less likely to undergo cardiac catheterization
  • Less likely to receive timely reperfusion therapy
  • More likely to report fatigue, dyspnea, indigestion, nausea or vomiting, palpitations, or weakness, although some studies have found fewer differences in presentation
• More likely to delay presentation
• Men with ACS:
  • More likely to report central chest pain

Factors associated with delayed presentation

• Female sex
• Older age
• Black or Hispanic race
• Low educational achievement
• Low socioeconomic status
• Key historical features to assess:
  • Quality: crushing/pressure (ACS), tearing/ripping (dissection), pleuritic/sharp (PE, pericarditis, pneumothorax)
  • Radiation: jaw/arm (ACS), back (dissection), shoulder (pericarditis)
  • Onset: sudden (PE, dissection, pneumothorax) vs gradual (ACS, musculoskeletal)
  • Associated symptoms: diaphoresis, dyspnea, nausea/vomiting, syncope
  • Risk factors: cardiac history, DVT/PE risk factors, cocaine use, connective tissue disease, recent procedure
• Red flags:
  • Hemodynamic instability
  • New ECG changes (ST elevation/depression, new LBBB)
  • Unequal blood pressures or pulses (aortic dissection)
  • Tracheal deviation, absent breath sounds (tension pneumothorax)
  • Subcutaneous emphysema (pneumomediastinum, esophageal perforation)

Differential Diagnosis

Chest pain

Critical

• Acute coronary syndromes (ACS)
  • STEMI
  • Non-STEMI
  • Unstable angina
• Aortic dissection
• Cardiac tamponade
• Coronary artery dissection
• Esophageal perforation (Boerhhaave's syndrome)
• Pulmonary embolism
• Tension pneumothorax

Emergent

• Cholecystitis
• Cocaine-associated chest pain
• Mediastinitis
• Myocardial rupture
• Myocarditis
• Pancreatitis
• Pericarditis
• Pneumothorax

Nonemergent

• Aortic stenosis
• Arthritis
• Asthma exacerbation
• Biliary colic
• Costochondritis
• Esophageal spasm
• Gastroesophageal reflux disease
• Herpes zoster / Postherpetic Neuralgia
• Hypertrophic cardiomyopathy
• Hyperventilation
• Mitral valve prolapse
• Panic attack
• Peptic ulcer disease
• Pleuritis
• Pneumomediastinum
• Pneumonia
• Rib fracture
• Stable angina
• Thoracic outlet syndrome
• Valvular heart disease
• Muscle sprain
• Psychologic / Somatic Chest Pain
• Spinal Root Compression
• Tumor

Evaluation

Workup

• All patients:
  • ECG - within 10 minutes of arrival; repeat if symptoms change or initially nondiagnostic
  • CXR
  • Vital signs including bilateral blood pressures if dissection suspected
• Moderate-to-high risk or concerning features:
  • Troponin - serial troponins (0h and 1-3h with high-sensitivity assay; 0h and 3-6h with conventional assay)
  • CBC, BMP
  • Consider coagulation studies
• Additional testing based on suspicion:
  • D-dimer or CT-PA - if PE suspected (use validated pretest probability tools: Wells score, PERC rule, YEARS algorithm)
  • CT angiography of chest/abdomen/pelvis - if aortic dissection suspected
  • BNP/NT-proBNP - if CHF suspected
  • Point-of-care echo - for pericardial effusion, RV strain, wall motion abnormalities, aortic root dilation

Risk Stratification

• HEART Score: Validated tool for risk stratification in undifferentiated chest pain
  • Score 0-3: Low risk; consider early discharge
  • Score 4-6: Moderate risk; admission/observation with serial troponins
  • Score 7-10: High risk; admission with cardiology consultation
• Wells score: For pretest probability of PE
• PERC rule: If low pretest probability, PERC can exclude PE without D-dimer

Management

• Treat based on underlying cause:
  • ACS: ASA, anticoagulation, cardiology consultation; PCI for STEMI (see ST-segment elevation myocardial infarction)
  • PE: Anticoagulation; thrombolytics for massive PE (see Pulmonary embolism)
  • Aortic dissection: HR and BP control; emergent surgical consultation for Type A (see Nontraumatic thoracic aortic dissection)
  • Tension pneumothorax: Needle decompression followed by chest tube
  • Pericardial tamponade: Pericardiocentesis
• Pain control: Avoid NSAIDs if ACS suspected; nitroglycerin for ischemic pain (avoid in RV infarct, recent PDE5 inhibitor use, hypotension)

Disposition

• Admit to ICU/monitored bed:
  • STEMI, unstable ACS, hemodynamically significant PE, aortic dissection, pericardial tamponade
• Admit/observe:
  • Moderate HEART score with pending serial troponins
  • NSTEMI awaiting cardiology evaluation
• Discharge:
  • Low HEART score (0-3) with negative serial troponins
  • Clear non-cardiac cause identified (e.g., musculoskeletal, GERD)
  • PE ruled out with validated approach
  • Arrange appropriate follow-up (PCP within 72 hours for intermediate-risk patients)

Calculators

HEART Score

HEART Score Calculator

Criteria	Select One
History	Slightly suspicious (0)	Moderately suspicious (+1)	Highly suspicious (+2)
EKG	Normal (0)	Non-specific repolarization disturbance (+1)	Significant ST deviation (+2)
Age	<45 (0)	45–64 (+1)	≥65 (+2)
Risk Factors HTN, hypercholesterolemia, DM, obesity (BMI >30), smoking, family hx CVD, or hx atherosclerotic disease	No known risk factors (0)	1–2 risk factors (+1)	≥3 risk factors or hx atherosclerotic disease (+2)
Initial Troponin	≤normal limit (0)	1–3× normal limit (+1)	>3× normal limit (+2)
HEART Score	/ 10

Interpretation

0–3	Low Risk — 0.9–1.7% risk of MACE. Consider discharge with outpatient follow-up.
4–6	Moderate Risk — 12–16.6% risk of MACE. Consider admission for observation and further workup.
7–10	High Risk — 50–65% risk of MACE. Consider early invasive measures (cardiology consult, catheterization).

References

Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-196. PMID 18665203. Backus BE, Six AJ, Kelder JC, et al. Prospective validation of the HEART score for chest pain patients. Int J Cardiol. 2013;168(3):2153-2158. PMID 23465250. Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial. Circ Cardiovasc Qual Outcomes. 2015;8(2):195-203. PMID 25737484.

See Also

• Acute coronary syndrome (main)
• ST-segment elevation myocardial infarction
• Pulmonary embolism
• Nontraumatic thoracic aortic dissection
• Pericarditis
• HEART Score
• Chest pain (peds)
• Cocaine chest pain