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Chest pain

Last updated: November 17, 2020

Summary

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), 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.

Management

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

Diagnostics

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

Cardiovascular causes

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

Gastrointestinal causes

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]

Pulmonary causes

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]
  • See the acute management checklist for asthma exacerbation.
COPD exacerbation [39][40]
Pleural effusion [41][42]

Other causes

Costochondritis [43]

Acute herpes zoster [44][45]

Panic disorder [46]

Functional chest pain [22][48]

Differential diagnoses

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

The differential diagnoses listed here are not exhaustive.

References

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