Table of Contents
Page created on April 9, 2022. Not updated since.
Introduction and epidemiology
Acute chest pain is a common cause of admission to the emergency department. Most cases are not life-threatening, but it’s important to rule out life-threatening causes.
Evaluation of chest pain
Everyone who is admitted with acute chest pain get:
- Blood test checking for troponins, D-dimer, amylase, + other general tests
- ECG
Further examinations are based on the examining physician’s differential diagnosis based on the patient’s clinical features. These may include:
- Echocardiography
- Imaging
- Arterial blood gas
Life-threatening causes
| Organ system | Cause | Typical features |
| Cardiac | Acute coronary syndrome | Heavy, dull, squeezing pain. Substernal pain with radiation to left shoulder. Nausea/vomiting. Sweating. Pain improves with nitroglycerine. Pathological ECG. Elevated troponins. |
| Aortic dissection | Sudden onset, severe, sharp, tearing chest or abdominal pain that radiates to the back. Hypotension. Syncope. Asymmetric blood pressure between the arms. | |
| Cardiac tamponade | Hypotension. Jugular venous distension. Distant heart sounds. Tachypnoea. Dyspnoea. Pulsus paradoxus. | |
| Chronic heart failure exacerbation | Cough. Pulmonary crackles. Jugular venous distension. Peripheral oedema. | |
| Takotsubo cardiomyopathy | Recent stressful event. Acute heart failure. | |
| Pulmonary | Pulmonary embolism | Acute onset. Pleuritic chest pain. Dyspnoea. Hypoxaemia. Cough. Haemoptysis. History of DVT or DVT risk factors. Obstructive shock if severe. ECG signs of right heart strain. |
| Tension pneumothorax | Severe, sharp chest pain. Dyspnoea. Hypoxaemia. History of trauma. Hyperresonance on percussion. Decreased breathing sounds on auscultation. | |
| Gastrointestinal | Oesophageal perforation | Retrosternal/neck/epigastric pain radiates to the back. Recent procedure near the oesophagus or severe emesis. Signs of sepsis. Vomiting. Subcutaneous emphysema. |
Non-life-threatening causes
| Organ system | Cause | Typical features |
| Cardiac | Stable angina | Retrosternal chest pain in relation to exercise, relieved with rest. Improves with nitroglycerine. Normal ECG and troponins. |
| Pericarditis | Sharp retrosternal pain, worsens on inspiration, improves when leaning forward. Pericardial friction rub on auscultation. | |
| Pulmonary | Pneumonia | Fever. Cough Ill appearance. Elevated inflammatory markers. |
| Asthma exacerbation | Known asthma or recurrent episodes of dry cough and wheezing. Worsening of known symptoms. Dyspnoea. Tachypnoea. Hypoxaemia. Silent chest on auscultation. Hyperresonance on percussion. | |
| COPD exacerbation | Known COPD or known cough + dyspnoea. Worsening of known symptoms. Purulent sputum. Tachypnoea. Wheezing. Hypoxaemia, hypercapnia. | |
| Gastrointestinal | Gastroesophageal reflux disease | Burning sensation substernally, aggravated in supinated position and after food. Epigastric tenderness. |
| Peptic ulcer disease | Pain either relieved or worsened by food. Known risk factors. | |
| Musculoskeletal | Costochondritis | Tenderness of the costochondral joint. Pain in the chest wall. Worsen with movement of the thorax, but not related to exercise. |
| Intercostal muscle strain | Tenderness and pain in the intercostal muscles. Don’t worsen with exercise. | |
| Other | Anxiety attack | Chest tightness. Palpitations. Tachypnoea. Diaphoresis. Anxious appearance. |
| Herpes zoster | Burning pain. Maculopapular/vesicular rash on the chest. |