Register / Log in

Trusted medical expertise in seconds.

Access 1,000+ clinical and preclinical articles. Find answers fast with the high-powered search feature and clinical tools.

Try free for 5 days
Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer.

Chest pain

Last updated: April 16, 2021

Summarytoggle arrow icon

Nontraumatic chest pain is one of the most common causes of emergency department visits and is common in both inpatients and outpatients. The differential diagnosis is broad and includes cardiac (e.g., acute coronary syndrome, pericarditis), gastrointestinal (e.g., GERD, gastritis, PUD), pulmonary (e.g., pulmonary embolism, tension pneumothorax), musculoskeletal (e.g., costochondritis), and psychiatric (e.g., generalized anxiety disorder, panic attack) etiologies. Any life-threatening causes of chest pain, such as acute coronary syndrome and pulmonary embolism, should be immediately evaluated and assessed. 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. Traumatic causes of chest pain are not addressed here.

Approach [1]

  1. ABCDE survey
  2. Obtain 12-lead ECG: If ECG shows STEMI, see “Treatment” in acute coronary syndrome.
  3. Establish IV access.
  4. Continuous telemetry and pulse oximetry
  5. Initiate supplemental O2 if there is evidence of hypoxemia.
  6. Perform a focused history and physical examination.
  7. Perform targeted diagnostics (see “Diagnostics” below) and further tests as required.
  8. Treat the underlying cause.

Red flags for chest pain

Immediately life-threatening causes

The diagnostic workup should be guided by the pretest probability of the diagnoses under consideration. The following list includes some commonly used diagnostic tools that can be helpful in diagnosing or ruling out possible etiologies in patients with undifferentiated chest pain.

Laboratory studies

Imaging

Characteristic clinical features Diagnostic findings Acute management
STEMI [4]
NSTEMI/UA [5]
  • ECG: nonspecific changes, including T-wave inversions, ST-segment depressions
  • Increased or normal troponin
  • TTE: Regional wall motion abnormalities may be present.
Aortic dissection [6][7][8]
Cardiac tamponade [9]
  • 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.
Pericarditis [10][11]
Heart failure exacerbation [12][13][14][15]
Takotsubo cardiomyopathy [16][17]
  • History of a recent stressful event
  • Retrosternal chest pain, dyspnea, heavy, dull, pressure/squeezing sensation
  • Hypotension, shock
  • Most common in elderly women

Noncardiac chest pain is most commonly due to gastrointestinal and musculoskeletal disorders. [18]

Characteristic clinical features Diagnostic findings Acute management
Esophageal perforation [19][20]

GERD and erosive esophagitis [22][23]
  • Postprandial substernal chest pain, pressure, burning, reflux symptoms
  • Aggravated by lying in the supine position and certain foods (e.g., coffee, spices)
  • Epigastric tenderness
Peptic ulcer disease [24][25][26]
Acute pancreatitis [27][28][29]
  • 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
Mallory-Weiss syndrome [30][31]
Characteristic clinical features Diagnostic findings Acute management
Pulmonary embolism [32]
Tension pneumothorax [33][34]
Pneumonia [35]
Spontaneous pneumothorax [33][36][37]
  • Sudden, sharp unilateral chest pain
  • Acute dyspnea
  • Hypoxemia
  • Hyperresonance, decreased breath sounds on affected side
  • Crepitus
  • History of lung disease or trauma
Asthma exacerbation [38]
COPD exacerbation [39][40]
Pleural effusion [41][42]

Costochondritis [43]

Acute herpes zoster [44][45]

Panic disorder [46]

Functional chest pain [22][48]

See also differential diagnosis of increased troponin and differential diagnosis of ST-elevations on ECG.

The differential diagnoses listed here are not exhaustive.

  1. Sherwood MW, Kristin Newby L. High‐Sensitivity Troponin Assays: Evidence, Indications, and Reasonable Use. Journal of the American Heart Association. 2014; 3 (1). doi: 10.1161/jaha.113.000403 . | Open in Read by QxMD
  2. Cayley WE Jr. Diagnosing the cause of chest pain.. Am Fam Physician. 2005; 72 (10): p.2012-21.
  3. Mavroudis CD, Kucharczuk JC. Acute Management of Esophageal Perforation. Current Surgery Reports. 2013; 2 (1). doi: 10.1007/s40137-013-0034-x . | Open in Read by QxMD
  4. Kaman L. Management of Esophageal Perforation in Adults. Gastroenterology Research. 2011 . doi: 10.4021/gr263w . | Open in Read by QxMD
  5. Søreide J, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2011; 19 (1): p.66. doi: 10.1186/1757-7241-19-66 . | Open in Read by QxMD
  6. Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology. 2008; 135 (4): p.1383-1391.e5. doi: 10.1053/j.gastro.2008.08.045 . | Open in Read by QxMD
  7. Gyawali CP, Fass R. Management of Gastroesophageal Reflux Disease. Gastroenterology. 2018; 154 (2): p.302-318. doi: 10.1053/j.gastro.2017.07.049 . | Open in Read by QxMD
  8. Kavitt RT, Lipowska AM, Anyane-Yeboa A, Gralnek IM. Diagnosis and Treatment of Peptic Ulcer Disease. Am J Med. 2019; 132 (4): p.447-456. doi: 10.1016/j.amjmed.2018.12.009 . | Open in Read by QxMD
  9. Satoh K, Yoshino J, Akamatsu T, et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol. 2016; 51 (3): p.177-194. doi: 10.1007/s00535-016-1166-4 . | Open in Read by QxMD
  10. Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician.. 2015; 91 (4): p.236-242.
  11. Crockett et al. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018; 154 (4): p.1096-1101. doi: 10.1053/j.gastro.2018.01.032 . | Open in Read by QxMD
  12. D Jeffrey. Acute Pancreatitis. AAFP. 2014 .
  13. Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology. 2018; 154 (4): p.1103-1139. doi: 10.1053/j.gastro.2018.01.031 . | Open in Read by QxMD
  14. Diffuse Esophageal Spasm. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/diffuse-esophageal-spasm. Updated: July 1, 2019. Accessed: November 15, 2019.
  15. Esophageal Motility Disorders. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/esophageal-motility-disorders#:~:targetText=Symptoms%20of%20esophageal%20motility%20disorders,pain%2C%20and%2For%20heartburn.. Updated: July 1, 2019. Accessed: November 15, 2019.
  16. Khalaf M, Chowdhary S, Elias PS, Castell D. Distal Esophageal Spasm: A Review. Am J Med. 2018; 131 (9): p.1034-1040. doi: 10.1016/j.amjmed.2018.02.031 . | Open in Read by QxMD
  17. Roman S, Kahrilas PJ. Management of Spastic Disorders of the Esophagus. Gastroenterol Clin North Am. 2013; 42 (1): p.27-43. doi: 10.1016/j.gtc.2012.11.002 . | Open in Read by QxMD
  18. Kim H-S. Endoscopic Management of Mallory-Weiss Tearing. Clin Endosc. 2015; 48 (2): p.102. doi: 10.5946/ce.2015.48.2.102 . | Open in Read by QxMD
  19. Mallory Weiss Syndrome. https://www.ncbi.nlm.nih.gov/books/NBK538190/. Updated: November 24, 2019. Accessed: January 6, 2020.
  20. Achem SR, Gerson LB. Distal Esophageal Spasm: An Update. Curr Gastroenterol Rep. 2013; 15 (9). doi: 10.1007/s11894-013-0325-5 . | Open in Read by QxMD
  21. Achalasia. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/achalasia. Updated: July 1, 2019. Accessed: November 15, 2019.
  22. O’Gara PT, Kushner FG, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation. 2013; 127 (4). doi: 10.1161/cir.0b013e3182742cf6 . | Open in Read by QxMD
  23. E. A. Amsterdam, N. K. Wenger, R. G. Brindis, D. E. Casey Jr., T. G. Ganiats, D. R. Holmes Jr., A. S. Jaffe, H. Jneid, R. F. Kelly, M. C. Kontos, G. N. Levine, P. R. Liebson, D. Mukherjee, E. D. Peterson, M. S. Sabatine, R. W. Smalling, S. J. Zieman. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. Journal of the American College of Cardiology. 2014 . doi: 10.1016/j.jacc.2014.09.017 . | Open in Read by QxMD
  24. Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes.. Circulation. 2005; 112 (24): p.3802-13. doi: 10.1161/CIRCULATIONAHA.105.534198 . | Open in Read by QxMD
  25. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Circulation. 2010; 121 (13): p.e266-369. doi: 10.1161/CIR.0b013e3181d4739e . | Open in Read by QxMD
  26. Marik PE, Rivera R. Hypertensive emergencies. Curr Opin Crit Care. 2011; 17 (6): p.569-580. doi: 10.1097/mcc.0b013e32834cd31d . | Open in Read by QxMD
  27. Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003; 349 (7): p.684-690. doi: 10.1056/nejmra022643 . | Open in Read by QxMD
  28. Snyder MJ, Bepko J, White M. Acute pericarditis: diagnosis and management.. Am Fam Physician. 2014; 89 (7): p.553-60.
  29. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015; 36 (42): p.2921-2964. doi: 10.1093/eurheartj/ehv318 . | Open in Read by QxMD
  30. Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med. 2018; 55 (5): p.635-646. doi: 10.1016/j.jemermed.2018.08.002 . | Open in Read by QxMD
  31. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017; 136 (6). doi: 10.1161/cir.0000000000000509 . | Open in Read by QxMD
  32. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary. J Am Coll Cardiol. 2013; 62 (16): p.1495-1539. doi: 10.1016/j.jacc.2013.05.020 . | Open in Read by QxMD
  33. Van Diepen S, Katz JN, Albert NM, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2017; 136 (16). doi: 10.1161/cir.0000000000000525 . | Open in Read by QxMD
  34. Ghadri J-R, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 2018; 39 (22): p.2032-2046. doi: 10.1093/eurheartj/ehy076 . | Open in Read by QxMD
  35. Ghadri J-R, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management. Eur Heart J. 2018; 39 (22): p.2047-2062. doi: 10.1093/eurheartj/ehy077 . | Open in Read by QxMD
  36. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016; 149 (2): p.315-352. doi: 10.1016/j.chest.2015.11.026 . | Open in Read by QxMD
  37. Leech C, Porter K, Steyn R, et al. The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh. Trauma. 2016; 19 (1): p.54-62. doi: 10.1177/1460408616664553 . | Open in Read by QxMD
  38. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emergency Medicine Journal. 2004; 22 (1): p.8-16. doi: 10.1136/emj.2003.010421 . | Open in Read by QxMD
  39. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007; 44 (Supplement_2): p.S27-S72. doi: 10.1086/511159 . | Open in Read by QxMD
  40. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.. Chest. 2001; 119 (2): p.590-602. doi: 10.1378/chest.119.2.590 . | Open in Read by QxMD
  41. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010; 65 (Suppl 2): p.ii18-ii31. doi: 10.1136/thx.2010.136986 . | Open in Read by QxMD
  42. Camargo CA, Rachelefsky G, Schatz M. Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations. Proc Am Thorac Soc. 2009; 6 (4): p.357-366. doi: 10.1513/pats.p09st2 . | Open in Read by QxMD
  43. Stoller JK. Acute Exacerbations of Chronic Obstructive Pulmonary Disease. N Engl J Med. 2002; 346 (13): p.988-994. doi: 10.1056/nejmcp012477 . | Open in Read by QxMD
  44. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). http://www.goldcopd.org. . Accessed: June 27, 2019.
  45. Hooper et al.. Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010. Thorax. undefined; 65 : p.ii4-ii17. doi: 10.1136/thx.2010.136978 . | Open in Read by QxMD
  46. Karkhanis V, Joshi J. Pleural effusion: diagnosis, treatment, and management. Open Access Emergency Medicine. 2012 : p.31. doi: 10.2147/oaem.s29942 . | Open in Read by QxMD
  47. Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment.. Am Fam Physician. 2009; 80 (6): p.617-20.
  48. Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the Management of Herpes Zoster. Clinical Infectious Diseases. 2007; 44 (Supplement_1): p.S1-S26. doi: 10.1086/510206 . | Open in Read by QxMD
  49. Saguil A, Kane S, Mercado M, Lauters R. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management.. Am Fam Physician. 2017; 96 (10): p.656-663.
  50. Fleet RP, Dupuis G, Marchand A, Burelle D, Arsenault A, Beitman BD. Panic disorder in emergency department chest pain patients: Prevalence, comorbidity, suicidal ideation, and physician recognition. Am J Med. 1996; 101 (4): p.371-380. doi: 10.1016/s0002-9343(96)00224-0 . | Open in Read by QxMD
  51. Greenslade JH, Hawkins T, Parsonage W, Cullen L. Panic Disorder in Patients Presenting to the Emergency Department With Chest Pain: Prevalence and Presenting Symptoms. Heart, Lung and Circulation. 2017; 26 (12): p.1310-1316. doi: 10.1016/j.hlc.2017.01.001 . | Open in Read by QxMD
  52. Remes-Troche JM. How to Diagnose and Treat Functional Chest Pain. Curr Treat Options Gastroenterol. 2016; 14 (4): p.429-443. doi: 10.1007/s11938-016-0106-y . | Open in Read by QxMD
  53. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical ; 2018
  54. Ranasinghe AM, Strong D, Boland B, Bonser RS. Acute aortic dissection. BMJ. 2011; 343 (jul29 2): p.d4487-d4487. doi: 10.1136/bmj.d4487 . | Open in Read by QxMD
  55. Khan AN, Cho KJ. Aortic Dissection Imaging. Aortic Dissection Imaging. New York, NY: WebMD. http://emedicine.medscape.com/article/416776-overview#showall. Updated: May 13, 2016. Accessed: December 4, 2016.
  56. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017; 112 : p.212-238. doi: 10.1038/ajg.2016.563 . | Open in Read by QxMD
  57. O'Connel TX, Movalia M. Brochert's Crush Step 2: The Ultimate USMLE Step 2 Review. Saunders ; 2012
  58. Stark P. Imaging of pneumothorax. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/imaging-of-pneumothorax.Last updated: March 1, 2017. Accessed: April 7, 2017.
  59. Basurto Ona et al. Opioids for acute pancreatitis pain. Cochrane Database of Systematic Reviews. 2013 . doi: 10.1002/14651858.cd009179.pub2 . | Open in Read by QxMD
  60. Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017; 18 (1): p.1-76. doi: 10.1089/sur.2016.261 . | Open in Read by QxMD
  61. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2013; 62 (16): p.e147-e239. doi: 10.1016/j.jacc.2013.05.019 . | Open in Read by QxMD
  62. Felker GM, Lee KL, Bull DA, et al. Diuretic Strategies in Patients with Acute Decompensated Heart Failure. N Engl J Med. 2011; 364 (9): p.797-805. doi: 10.1056/nejmoa1005419 . | Open in Read by QxMD
  63. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. Circulation. 2016; 133 (14): p.e506–e574. doi: 10.1161/cir.0000000000000311 . | Open in Read by QxMD
  64. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014; 64 (21): p.e1-e76. doi: 10.1016/j.jacc.2014.03.022 . | Open in Read by QxMD
  65. Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Advances. 2018; 2 (22): p.3198-3225. doi: 10.1182/bloodadvances.2018022954 . | Open in Read by QxMD
  66. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo Cardiomyopathy. Circulation. 2008; 118 (25): p.2754-2762. doi: 10.1161/circulationaha.108.767012 . | Open in Read by QxMD
  67. Salas M, Ward A, Caro J. Are proton pump inhibitors the first choice for acute treatment of gastric ulcers? A meta analysis of randomized clinical trials. BMC Gastroenterol. 2002; 2 (1). doi: 10.1186/1471-230x-2-17 . | Open in Read by QxMD
  68. Brenner B, Corbridge T, Kazzi A. Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory Failure. Proc Am Thorac Soc. 2009; 6 (4): p.371-379. doi: 10.1513/pats.p09st4 . | Open in Read by QxMD
  69. Loffroy R, Favelier S, Pottecher P, et al. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging. 2015; 96 (7-8): p.731-744. doi: 10.1016/j.diii.2015.05.002 . | Open in Read by QxMD
  70. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018; 67 (3): p.103-108. doi: 10.15585/mmwr.mm6703a5 . | Open in Read by QxMD