Chest pain accounts for over 7.8 million ED visits annually in the United States. [1] The primary goal is rapid identification of life-threatening causes — ACS, aortic dissection, pulmonary embolism, tension pneumothorax, esophageal rupture, and pericardial tamponade — while recognizing that the majority of presentations are noncardiac and benign. [2-3]
1. History
- Quality: Pressure, tightness, squeezing, heaviness, or burning → more consistent with ACS. Sharp, fleeting, pleuritic, positional, or point-localized → less likely ischemic. [3-4]
- Onset/timing: Sudden, maximal-at-onset ("tearing/ripping") → aortic dissection. Gradual crescendo → ACS. Postprandial → GI etiology.
- Duration: Seconds of fleeting pain → low concern for ischemia. >20 min continuous → ACS until proven otherwise. Days of constant pain → musculoskeletal, pericarditis.
- Location/radiation: Substernal radiating to left arm, jaw, neck → ACS. Interscapular → aortic dissection. Dermatomal → herpes zoster.
- Provoking/relieving factors: Exertional → ischemia, HCM. Pleuritic (worse with inspiration) → PE, pericarditis, pneumonia, pneumothorax. Worse supine, better leaning forward → pericarditis. Postprandial/positional → GERD/esophageal. Reproducible with palpation → musculoskeletal (but does not exclude ACS).
- Associated symptoms: Diaphoresis, nausea, dyspnea → ACS. Hemoptysis → PE. Dysphagia, odynophagia → esophageal. Fever → pneumonia, pericarditis, myocarditis.
- Important negatives: No response to nitroglycerin does NOT rule out cardiac chest pain. Women, elderly, and diabetic patients more often present with dyspnea, nausea, fatigue, or syncope rather than classic chest pain. [5]
- The 2021 AHA/ACC guideline discourages the term "atypical" and recommends classifying pain as cardiac, possible cardiac, or noncardiac. [3][5]
2. Alarm Features
- Hemodynamic instability (hypotension, tachycardia, altered mental status)
- New ST elevation or dynamic ECG changes
- Diaphoresis with substernal pressure
- Sudden-onset severe "tearing" pain radiating to back (aortic dissection)
- Unilateral absent breath sounds (tension pneumothorax)
- Subcutaneous emphysema (esophageal rupture, pneumomediastinum)
- Pulse differential between extremities (aortic dissection — sensitivity ~30%, but severe pain + pulse differential + widened mediastinum = >80% probability) [3]
- Signs of acute heart failure: crackles, S3, JVD, new MR murmur [4]
- Syncope in the setting of chest pain (dissection, PE, arrhythmia)
3. Medications
Relevant medication contributors to chest pain
- Cocaine/amphetamines → coronary vasospasm, ACS
- 5-fluorouracil, capecitabine → coronary vasospasm [3]
- PDE5 inhibitors → contraindicate nitrate use (sildenafil/vardenafil within 24 h, tadalafil within 48 h, avanafil within 12 h) [6]
- NSAIDs → peptic ulcer disease, GI bleeding
- Bisphosphonates → esophagitis
Common acute treatments by etiology
4. Diet
- GERD-related chest pain: Avoid caffeine, alcohol, spicy/fatty foods, chocolate, citrus, late-night meals; elevate head of bed.
- ACS/cardiovascular: Mediterranean-style diet, sodium restriction if hypertensive or heart failure.
- Acute setting: NPO if procedural intervention anticipated (catheterization, surgery).
5. Review of Systems
- Cardiovascular: Palpitations, syncope/presyncope, exertional dyspnea, orthopnea, PND, leg swelling
- Pulmonary: Cough, hemoptysis, pleurisy, recent immobilization/travel
- GI: Dysphagia, odynophagia, heartburn, nausea/vomiting, hematemesis, melena
- MSK: Trauma, repetitive strain, recent heavy lifting
- Neuro: Focal weakness (aortic dissection with malperfusion)
- Psych: Panic symptoms, anxiety, hyperventilation, paresthesias
- Derm: Vesicular rash in dermatomal distribution (herpes zoster)
- Constitutional: Fever, weight loss, night sweats (malignancy, endocarditis, TB)
6. Collateral History and Family History
- Collateral: Witnessed diaphoresis, syncope, or altered mental status; medication compliance; substance use (cocaine, methamphetamine); recent procedures or surgeries
- Family history: Premature CAD (first-degree relative: male <55, female <65), sudden cardiac death, aortic aneurysm/dissection (Marfan, Ehlers-Danlos, Loeys-Dietz), familial hypercholesterolemia, HCM [4]
- Social context: Smoking status, illicit drug use, occupational exposures, recent travel/immobilization (VTE risk), psychosocial stressors
7. Risk Factors
- For ACS: Hypertension, hyperlipidemia, diabetes, smoking, obesity (BMI >30), family history of premature CAD, prior MI/PCI/CABG, peripheral arterial disease [4]
- For PE: Recent surgery/immobilization, malignancy, OCP/HRT use, prior VTE, thrombophilia, obesity, long-haul travel
- For aortic dissection: Uncontrolled hypertension, connective tissue disorders (Marfan, Ehlers-Danlos), bicuspid aortic valve, prior aortic surgery, cocaine use, pregnancy [3]
- For pericarditis: Recent viral illness, autoimmune disease, post-cardiac surgery/procedure, malignancy, uremia [7]
- Age-specific: MI prevalence ranges from ~1% in patients 18–44 years to ~4% in patients ≥80 years presenting with nontraumatic chest pain [1]
8. Differential Diagnosis
Life-threatening ("cannot miss")
- ACS (STEMI, NSTEMI, unstable angina)
- Acute aortic syndrome (dissection, intramural hematoma, penetrating ulcer)
- Pulmonary embolism
- Tension pneumothorax
- Esophageal rupture (Boerhaave syndrome)
- Cardiac tamponade / fulminant myocarditis
Cardiac (non-ACS)
Pulmonary
GI
Musculoskeletal
Other
9. Past Medical History
- Prior ACS, PCI, CABG, or known CAD (informs risk stratification and testing strategy) [4]
- Prior normal stress test (<1 year) or coronary angiogram (<2 years) — may allow earlier discharge [8]
- Prior aortic aneurysm, valve disease, or connective tissue disorder
- History of VTE, malignancy, or hypercoagulable state
- GERD, PUD, or prior GI surgery
- Psychiatric history (panic disorder, anxiety, somatization)
- Sickle cell disease
10. Physical Exam
Vital signs: Blood pressure in both arms (>20 mmHg differential → dissection), heart rate, respiratory rate, SpO2, temperature [3-4]
Key findings by diagnosis
Pearl: There are no physical exam findings specific for coronary ischemia — the exam is primarily used to identify high-risk features and alternative diagnoses. [4]
11. Lab Studies
- High-sensitivity cardiac troponin (hs-cTn): Most accurate and earliest marker of myocardial injury. Serial measurement at 0 and 1–3 hours (hs-cTn) or 0 and 3–6 hours (conventional). A single hs-cTn below the limit of detection ≥3 hours after symptom onset can reasonably exclude myocardial injury. [2-3][5]
- CK-MB and myoglobin are NOT recommended for diagnosis or prognosis. [5]
- BNP/NT-proBNP: If heart failure suspected.
- D-dimer: If PE suspected (use age-adjusted cutoff; high sensitivity, low specificity).
- CBC, BMP, coagulation studies: Baseline; assess for anemia, renal function, electrolytes.
- Lipase: If pancreatitis considered.
- CRP/ESR: If pericarditis suspected (CRP useful for guiding NSAID taper). [7]
- Lactate, VBG/ABG: If hemodynamically unstable or sepsis suspected.
- Urine drug screen: If cocaine/stimulant use suspected.
12. Imaging
- Chest X-ray: Should be performed in almost all patients with possible ACS. Identifies pneumonia, pneumothorax, rib fracture, widened mediastinum, pulmonary edema. A normal CXR does NOT rule out aortic dissection. [4-5]
- Point-of-care ultrasound (POCUS): Invaluable for rapid assessment — wall motion abnormalities (ACS vs myocarditis), RV dilation (PE), pericardial effusion/tamponade, aortic root dilation, pneumothorax. [2]
- CT angiography (CTA) chest: Gold standard for PE and aortic dissection. Triple rule-out CTA can assess coronary arteries, aorta, and pulmonary arteries simultaneously in select patients.
- Coronary CTA: Recommended for intermediate-risk patients with negative/inconclusive ACS workup; decreases time to diagnosis by 50% compared with nuclear stress testing. [5]
- Echocardiography (TTE): Recommended for intermediate-risk patients to assess ventricular function, wall motion, valvular disease, and pericardial effusion. [3]
- Low-risk patients with acute chest pain do NOT benefit from stress testing or cardiac imaging within 30 days of initial visit. [5]
13. Special Tests
Risk stratification scores
The HEART Pathway is the most widely validated clinical decision pathway for ED chest pain evaluation, combining the HEART score with serial troponin to identify patients safe for early discharge. [4][8]
- HEART score ≤3 + nonischemic ECG + serial troponin <99th percentile → low risk, eligible for early discharge (30-day MACE rate <1%) [4]
- EDACS <16 is an alternative validated pathway [4]
- Wells score / Geneva score: For PE risk stratification
- PERC rule: To exclude PE without D-dimer in very low-risk patients
- POCUS: Bedside cardiac, lung, and aortic assessment
14. ECG
- 12-lead ECG within 10 minutes of arrival — this is a Class I recommendation. [5]
- Repeat ECG if initial is normal but clinical suspicion remains high; up to 6% of patients with ischemia are discharged after a single normal ECG. [5]
- Add leads V7–V9 on repeat testing to assess for posterior MI. [5]
Key ECG patterns
15. Assessment
- Chest pain is a symptom, not a diagnosis — the clinical priority is systematic exclusion of life-threatening etiologies followed by risk stratification for ACS.
- Most ED chest pain patients are low risk; the majority have noncardiac causes (musculoskeletal, GI, psychiatric). [2-3]
- Severity stratification should use a validated clinical decision pathway (HEART, EDACS, or hs-cTn–based ESC algorithm) to categorize patients into low, intermediate, and high risk. [2-3][9]
- Beware of atypical presentations in women, elderly, and diabetic patients — these populations are at higher risk for missed ACS. [5]
- Pericarditis accounts for up to 5% of ED visits for nonischemic chest pain; with appropriate treatment, 70–85% have a benign course. [7]
16. Treatment Plan
Initial stabilization (all undifferentiated chest pain)
- IV access, continuous cardiac monitoring, pulse oximetry
- 12-lead ECG within 10 minutes
- Supplemental O2 only if SpO2 <90% (routine O2 is NOT recommended in non-hypoxic ACS) [1]
If ACS suspected
- ASA 162–325 mg (chewed, non-enteric coated) [1][6]
- NTG 0.4 mg SL q5min ×3 (if SBP ≥90, no RV infarct, no recent PDE5 inhibitor) [6]
- IV NTG for persistent pain, hypertension, or pulmonary edema [6]
- Anticoagulation per ACS protocol (heparin)
- Morphine 2–4 mg IV or fentanyl 25–50 μg IV for refractory pain (note: may delay P2Y12 absorption) [6]
- STEMI → emergent catheterization/PCI
If pericarditis
If PE confirmed
If musculoskeletal
17. Disposition
Discharge criteria (low risk)
- HEART score ≤3 (or EDACS <16) + nonischemic ECG + serial hs-cTn below limit of detection or <99th percentile → eligible for discharge without further testing [2][4-5]
- Single hs-cTn below limit of detection is reasonable if symptoms began ≥3 hours prior and ECG is normal [3]
Observation unit
Admission criteria
- STEMI or NSTE-ACS → cardiology admission
- High-risk CDP classification (HEART ≥7, rising troponin, ischemic ECG changes) → admission with consideration for coronary angiography [4]
- Hemodynamic instability, significant arrhythmia, acute heart failure [4]
- Confirmed or high-suspicion aortic dissection, massive PE, tension pneumothorax, esophageal rupture → emergent intervention
Specialist consultation triggers
- Cardiology: ACS, new heart failure, significant arrhythmia, valvular emergency
- Cardiothoracic surgery: Aortic dissection (Type A), esophageal rupture
- Pulmonology/IR: Massive PE requiring thrombolysis or thrombectomy
18. Follow Up / Return Precautions
Follow-up timing
- Low-risk patients discharged from ED → PCP or cardiology follow-up within 7 days [4]
- Intermediate-risk patients discharged after normal predischarge testing → longer follow-up window is reasonable, but close follow-up still recommended [4]
- Patients with type 2 MI or myocardial injury → outpatient cardiology follow-up recommended (associated with greater initiation of secondary prevention and potentially improved outcomes) [4]
Return precautions — instruct patients to return immediately for:
- Recurrence or worsening of chest pain
- New shortness of breath, syncope, or near-syncope
- Palpitations or feeling of rapid/irregular heartbeat
- New arm/jaw pain, diaphoresis, or nausea with chest discomfort
- Any symptom that feels different or more severe than the initial presentation
Patient counseling
- Explain that a negative ED workup reduces but does not eliminate cardiac risk
- Emphasize importance of follow-up appointment and risk factor modification (smoking cessation, BP/cholesterol management, diabetes control)
- Advise against cocaine/stimulant use
- Expected recovery course depends on etiology: musculoskeletal pain may take days to weeks; pericarditis typically improves within 1–2 weeks with treatment [7]
The following figure illustrates a practical evaluation algorithm for acute coronary syndrome workup, including the integration of the Marburg Heart Score, serial troponin, and HEART score into a stepwise decision pathway:
References
1. 2024 American Heart Association and American Red Cross Guidelines for First Aid. — Hewett Brumberg EK, Douma MJ, Alibertis K, et al. Circulation. 2024.
2. Navigating a Complicated World: The American Heart Association/American College of Cardiology/American College of Chest Physicians/Society of Academic Emergency Medicine/Society of Cardiovascular Computed Tomography/Society of Cardiovascular Magnetic Resonance Chest Pain Guidelines. — Hollenberg SM, Gentile F, Jumean M, et al. Chest. 2022.
3. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. — Gulati M, Levy PD, Mukherjee D, et al. Journal of the American College of Cardiology. 2021.
4. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain In the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. — Kontos MC, de Lemos JA, Deitelzweig SB, et al. Journal of the American College of Cardiology. 2022.
5. Chest Pain Evaluation: Updated Guidelines From the AHA/ACC. — Buelt A, Kennady J, Arnold M. American Family Physician. 2023.
6. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. — Rao SV, O'Donoghue ML, Ruel M, et al. Journal of the American College of Cardiology. 2025.
7. Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review. — Cremer PC, Klein AL, Imazio M. The Journal of the American Medical Association. 2024.
8. Validation of the ACC Expert Consensus Decision Pathway for Patients With Chest Pain. — Mahler SA, Ashburn NP, Supples MW, Hashemian T, Snavely AC. Journal of the American College of Cardiology. 2024.
9. Care Models for Acute Chest Pain That Improve Outcomes and Efficiency: JACC State-of-the-Art Review. — Dawson LP, Smith K, Cullen L, et al. Journal of the American College of Cardiology. 2022.
10. Acute Coronary Syndrome: Diagnosis and Initial Management. — Nohria R, Viera AJ. American Family Physician. 2024.