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Emergency and acute medicine – Chest Pain
Overview
Chest pain is one of the most common presenting complaints in the emergency department and frequently represents a potentially life-threatening condition such as acute coronary syndrome, pulmonary embolism, or aortic dissection. Until proven otherwise, chest pain should always be considered dangerous. Although categorization can suggest etiology, presentations are often variable, vague, and misleading.
Anatomic patterns of pain
Thoracic pain arises from structures such as the myocardium, pericardium, ascending aorta, pulmonary artery, mediastinum, or esophagus. It is typically deep, visceral, and poorly localized, ranging from crushing pressure to burning or indigestion-like discomfort.
Epigastric pain may originate from the descending aorta, diaphragm, gallbladder, pancreas, duodenum, or stomach and is often referred to the xiphoid area or back.
Pleuritic pain results from inflammation or trauma of ribs, muscles, pleura, or pericardium and worsens with breathing, coughing, laughing, or sneezing; tenderness to palpation may be present.
Diaphragmatic pleurisy causes sharp epigastric, lower retrosternal, or shoulder pain that intensifies with thoracic movement.
Chest wall pain involves skin and subcutaneous structures and is reproducible with palpation, arm movement, neck extension, or vertical pressure on the head.
Causes
Thoracic causes include acute coronary syndrome, myocarditis, pericarditis, stress-induced cardiomyopathy, stimulant use, thoracic aortic dissection, and esophageal disorders such as reflux, spasm, rupture, or mediastinitis.
Epigastric causes include descending aortic dissection, peptic ulcer disease, pancreatitis, cholecystitis, splenic or hepatic injury, and subdiaphragmatic abscess.
Pleuritic pain may result from pulmonary embolism, pneumothorax, pneumonia, costochondritis, or sickle cell acute chest syndrome.
Chest wall causes include musculoskeletal strain, rib fractures, herpes zoster, thrombophlebitis, xiphisternal arthritis, and breast pathology.
Clinical features
Coronary ischemia commonly presents with pressure-like or squeezing pain radiating to the arm or jaw, associated with dyspnea, diaphoresis, nausea, vomiting, weakness, or fatigue, especially in women and older adults.
Aortic dissection typically causes sudden, severe pain with maximal intensity at onset, often tearing and radiating to the back or flank, accompanied by hypertension, pulse deficits, murmurs, syncope, or neurologic symptoms.
Pulmonary embolism presents with pleuritic pain, dyspnea, anxiety, tachycardia, tachypnea, syncope, or low-grade fever.
Acute pericarditis causes substernal pain worsened by lying flat and relieved by leaning forward, often with fever and a friction rub.
Pneumothorax produces sudden pleuritic pain with dyspnea and unilateral decreased breath sounds.
History and examination
History is the most critical diagnostic tool and should focus on onset, duration, location, quality, radiation, provoking and relieving factors, associated symptoms, and prior cardiac risk factors. Physical examination should include careful cardiac, pulmonary, vascular, abdominal, and skin assessments, looking for murmurs, rubs, breath sound asymmetry, pulse deficits, abdominal tenderness, or zoster lesions.
Investigations
An electrocardiogram should be obtained and interpreted within 10 minutes of arrival, with serial tracings when suspicion for acute coronary syndrome persists. Laboratory testing is individualized based on risk and presentation and may include cardiac biomarkers and D-dimer in selected low-risk patients.
Chest radiography evaluates for pneumothorax, pneumonia, heart failure, mediastinal widening, or esophageal rupture. Computed tomography is useful for pulmonary embolism and aortic dissection. Ultrasound and echocardiography rapidly assess pericardial effusion, valvular disease, right ventricular strain, pneumothorax, and pleural effusion.
Management principles
Prehospital and early emergency care should be guided by risk assessment and may include intravenous access, cardiac monitoring, oxygen, aspirin, nitrates, and analgesia when a cardiac cause is suspected.
Initial stabilization focuses on airway, breathing, circulation, oxygenation, intravenous access, and continuous monitoring. Definitive treatment depends on the suspected underlying cause and should not be delayed in high-risk presentations.
Disposition and follow-up
Admission decisions depend on the likelihood of life-threatening cardiopulmonary disease. Patients deemed low risk after thorough evaluation may be discharged with close outpatient follow-up. Patients should receive clear return precautions for persistent, worsening, or recurrent chest pain, associated dyspnea, diaphoresis, syncope, or radiation of pain.
Clinical cautions
Avoid reliance on a single cardiac biomarker, response to medications, or a single electrocardiogram. Serial ECGs and reassessment are essential in patients with suspected acute coronary syndrome or recurrent symptoms.
Overview
Chest pain is one of the most common presenting complaints in the emergency department and frequently represents a potentially life-threatening condition such as acute coronary syndrome, pulmonary embolism, or aortic dissection. Until proven otherwise, chest pain should always be considered dangerous. Although categorization can suggest etiology, presentations are often variable, vague, and misleading.
Anatomic patterns of pain
Thoracic pain arises from structures such as the myocardium, pericardium, ascending aorta, pulmonary artery, mediastinum, or esophagus. It is typically deep, visceral, and poorly localized, ranging from crushing pressure to burning or indigestion-like discomfort.
Epigastric pain may originate from the descending aorta, diaphragm, gallbladder, pancreas, duodenum, or stomach and is often referred to the xiphoid area or back.
Pleuritic pain results from inflammation or trauma of ribs, muscles, pleura, or pericardium and worsens with breathing, coughing, laughing, or sneezing; tenderness to palpation may be present.
Diaphragmatic pleurisy causes sharp epigastric, lower retrosternal, or shoulder pain that intensifies with thoracic movement.
Chest wall pain involves skin and subcutaneous structures and is reproducible with palpation, arm movement, neck extension, or vertical pressure on the head.
Causes
Thoracic causes include acute coronary syndrome, myocarditis, pericarditis, stress-induced cardiomyopathy, stimulant use, thoracic aortic dissection, and esophageal disorders such as reflux, spasm, rupture, or mediastinitis.
Epigastric causes include descending aortic dissection, peptic ulcer disease, pancreatitis, cholecystitis, splenic or hepatic injury, and subdiaphragmatic abscess.
Pleuritic pain may result from pulmonary embolism, pneumothorax, pneumonia, costochondritis, or sickle cell acute chest syndrome.
Chest wall causes include musculoskeletal strain, rib fractures, herpes zoster, thrombophlebitis, xiphisternal arthritis, and breast pathology.
Clinical features
Coronary ischemia commonly presents with pressure-like or squeezing pain radiating to the arm or jaw, associated with dyspnea, diaphoresis, nausea, vomiting, weakness, or fatigue, especially in women and older adults.
Aortic dissection typically causes sudden, severe pain with maximal intensity at onset, often tearing and radiating to the back or flank, accompanied by hypertension, pulse deficits, murmurs, syncope, or neurologic symptoms.
Pulmonary embolism presents with pleuritic pain, dyspnea, anxiety, tachycardia, tachypnea, syncope, or low-grade fever.
Acute pericarditis causes substernal pain worsened by lying flat and relieved by leaning forward, often with fever and a friction rub.
Pneumothorax produces sudden pleuritic pain with dyspnea and unilateral decreased breath sounds.
History and examination
History is the most critical diagnostic tool and should focus on onset, duration, location, quality, radiation, provoking and relieving factors, associated symptoms, and prior cardiac risk factors. Physical examination should include careful cardiac, pulmonary, vascular, abdominal, and skin assessments, looking for murmurs, rubs, breath sound asymmetry, pulse deficits, abdominal tenderness, or zoster lesions.
Investigations
An electrocardiogram should be obtained and interpreted within 10 minutes of arrival, with serial tracings when suspicion for acute coronary syndrome persists. Laboratory testing is individualized based on risk and presentation and may include cardiac biomarkers and D-dimer in selected low-risk patients.
Chest radiography evaluates for pneumothorax, pneumonia, heart failure, mediastinal widening, or esophageal rupture. Computed tomography is useful for pulmonary embolism and aortic dissection. Ultrasound and echocardiography rapidly assess pericardial effusion, valvular disease, right ventricular strain, pneumothorax, and pleural effusion.
Management principles
Prehospital and early emergency care should be guided by risk assessment and may include intravenous access, cardiac monitoring, oxygen, aspirin, nitrates, and analgesia when a cardiac cause is suspected.
Initial stabilization focuses on airway, breathing, circulation, oxygenation, intravenous access, and continuous monitoring. Definitive treatment depends on the suspected underlying cause and should not be delayed in high-risk presentations.
Disposition and follow-up
Admission decisions depend on the likelihood of life-threatening cardiopulmonary disease. Patients deemed low risk after thorough evaluation may be discharged with close outpatient follow-up. Patients should receive clear return precautions for persistent, worsening, or recurrent chest pain, associated dyspnea, diaphoresis, syncope, or radiation of pain.
Clinical cautions
Avoid reliance on a single cardiac biomarker, response to medications, or a single electrocardiogram. Serial ECGs and reassessment are essential in patients with suspected acute coronary syndrome or recurrent symptoms.
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