Chest pain
Last updated: November 17, 2020Summary
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
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.
Imaging
Cardiovascular causes
| Characteristic clinical features | Diagnostic findings | Acute management |
STEMI [4]
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|
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NSTEMI/UA [5]
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ECG: nonspecific changes, including T-wave inversions, ST-segment depressions
- Increased or normal troponin
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TTE: Regional wall motion abnormalities may be present.
|
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Aortic dissection [6][7][8]
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|
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Cardiac tamponade [9]
|
|
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ECG: low voltage, electrical alternans
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CXR: enlarged cardiac silhouette
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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.
|
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Pericarditis [10][11]
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Heart failure exacerbation [12][13][14][15]
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|
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Takotsubo cardiomyopathy [16][17]
|
- History of a recent stressful event
- Retrosternal chest pain, dyspnea, heavy, dull, pressure/squeezing sensation
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Hypotension, shock
- Most common in elderly women
|
|
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Gastrointestinal causes
Pulmonary causes
Other causes
Costochondritis [43]
- Clinical features
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Sharp, well-localized pain that is reproducible on palpation of costal cartilage
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History of recent exercise/exertion/chest wall trauma
- Diagnostics:
- Clinical diagnosis [43]
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CXR: normal
- Treatment:
- Clinical features
- Diagnostics:
- Treatment:
- Clinical features:
- Diagnostics: Clinical diagnosis
- Treatment:
Functional chest pain [22][48]
- Clinical features:
- Diagnostics:
- Treatment:
- Reassure the patient.
- Referral to psychologist [48]
- Consider initiating medical therapy with one of the following:
Differential diagnoses
References
-
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
-
Cayley WE Jr. Diagnosing the cause of chest pain.. Am Fam Physician. 2005; 72
(10): p.2012-21.
-
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
-
Kaman L. Management of Esophageal Perforation in Adults. Gastroenterology Research. 2011
.
doi: 10.4021/gr263w . | Open in Read by QxMD
-
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
-
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
-
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
-
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
-
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
-
Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician.. 2015; 91
(4): p.236-242.
-
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
-
D Jeffrey. Acute Pancreatitis. AAFP. 2014
.
-
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
-
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.
-
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.
-
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
-
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
-
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
-
Mallory Weiss Syndrome.
https://www.ncbi.nlm.nih.gov/books/NBK538190/.
Updated: November 24, 2019.
Accessed: January 6, 2020.
-
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
-
Achalasia.
https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/achalasia.
Updated: July 1, 2019.
Accessed: November 15, 2019.
-
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
-
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
-
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
-
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
-
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
-
Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003; 349
(7): p.684-690.
doi: 10.1056/nejmra022643 . | Open in Read by QxMD
-
Snyder MJ, Bepko J, White M. Acute pericarditis: diagnosis and management.. Am Fam Physician. 2014; 89
(7): p.553-60.
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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.
-
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
-
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
-
Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment.. Am Fam Physician. 2009; 80
(6): p.617-20.
-
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
-
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.
-
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
-
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
-
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
-
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
-
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
- 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.
-
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
-
O'Connel TX, Movalia M. Brochert's Crush Step 2: The Ultimate USMLE Step 2 Review.
Saunders
; 2012
- 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.
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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