Chest pain

Last updated: June 15, 2022

Summarytoggle arrow icon

Nontraumatic chest pain is one of the most common reasons that patients visit the emergency department; it is also frequently encountered in both the inpatient and outpatient settings. The differential diagnosis is broad and includes cardiac (e.g., acute coronary syndrome, pericarditis), gastrointestinal (e.g., gastritis, peptic ulcer disease), pulmonary (e.g., pulmonary embolism, tension pneumothorax), musculoskeletal (e.g., costochondritis, rib contusion), and psychiatric (e.g., generalized anxiety disorder, panic disorder) etiologies. Patients with red flag features suggestive of life-threatening causes (e.g., acute coronary syndrome, pulmonary embolism) and those who are hemodynamically unstable require immediate assessment. 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.

For traumatic causes of chest pain, see “Blunt chest trauma” and “Penetrating chest trauma.”

The following recommendations are consistent with the 2021 American Heart Association (AHA) chest pain guidelines. [1]

Approach [1][2][3]

Begin management of hemodynamic instability (e.g., shock, hypertensive emergency), signs of respiratory distress, and/or respiratory failure (e.g., hypoxia, hypercapnia) as soon as they are identified.

Red flags in chest pain [1][5]

Chest tightness with radiation to the left arm, jaw, and/or back that is associated with dyspnea should be considered cardiac chest pain until proven otherwise. [1]

Immediately life-threatening causes of chest pain [1]

The diagnostic evaluation of undifferentiated chest pain aims to first rule out immediately life-threatening causes of chest pain and then determine the etiology, guided by the pretest probability of the diagnoses under consideration.

Perform a 12-lead ECG for all patients with new or evolving chest pain as soon as possible, e.g., for timely identification of acute coronary syndrome.

Laboratory studies

Routine investigations

Applicable to most patients with undifferentiated chest pain

Additional investigations

Consider ordering the following studies concurrently with routine studies based on clinical assessment and pretest probability:

Imaging

Imaging is often required to confirm the diagnosis and rule out differential diagnoses. The choice of initial modality is usually based on the patient's clinical status, the pretest probability of the underlying etiology, and resource availability.

Bedside investigations

The following studies can be performed on unstable patients in most emergency settings:

Additional investigations

The following studies typically require the patient to be stable enough for transfer to a dedicated imaging suite:

Cardiovascular causes of chest pain
Causes Characteristic clinical features Diagnostic findings Acute management
STEMI [7]
NSTEMI/UA [8]
Aortic dissection [9][10][11]
Cardiac tamponade [12]
  • 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 [13][14]
Heart failure exacerbation [15][16][17][18]
Takotsubo cardiomyopathy [19][20]
Thoracic aortic aneurysm

Pulmonary causes of chest pain
Causes Characteristic clinical features Diagnostic findings Acute management
Pulmonary embolism [21]
Tension pneumothorax [22][23]
Pneumonia [24]
Spontaneous pneumothorax [22][25][26]
  • Sudden, sharp unilateral chest pain
  • Acute dyspnea
  • Hypoxemia
  • Hyperresonance on percussion, decreased breath sounds on the affected side
  • Crepitus
  • History of lung disease or trauma
Asthma exacerbation [27]
COPD exacerbation [28][29]
Pleural effusion [30][31]

Gastrointestinal causes of chest pain
Causes Characteristic clinical features Diagnostic findings Acute management
Esophageal perforation [32][33]

GERD and erosive esophagitis [35][36]

  • Postprandial substernal chest pain, pressure, burning, reflux symptoms
  • Aggravated by lying in the supine position and certain foods (e.g., coffee, spices)
  • Epigastric tenderness
Gastritis [37]
Peptic ulcer disease [38][39][40]
Acute pancreatitis [41][42][43]
  • 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

Esophageal hypermotility disorders [44][45][46][47]

  • Episodic retrosternal chest pain
  • Intermittent dysphagia, globus sensation
  • Reflux symptoms
  • Symptoms aggravated by stress and/or hot and cold food and drink
Mallory-Weiss syndrome [48][49]

Noncardiac chest pain is most commonly caused by gastrointestinal and musculoskeletal disorders. [50]

Costochondritis [51]

Herpes zoster [52][53]

Panic disorder [54]

Functional chest pain [35][56]

Cardiac

See also ”Differential diagnosis of increased troponin” and “Differential diagnosis of ST elevations on ECG.”

Pulmonary

Musculoskeletal

Gastrointestinal

Renal

Dermatological

Hematologic/Oncologic

Rheumatologic

Psychiatric

The differential diagnoses listed here are not exhaustive.

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  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. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary. J Am Coll Cardiol. 2021; 78 (22): p.2218-2261. doi: 10.1016/j.jacc.2021.07.052 . | Open in Read by QxMD
  3. Kreuter M, Mathis G. Emergency ultrasound of the chest.. Respiration. 2014; 87 (2): p.89-97. doi: 10.1159/000357685 . | Open in Read by QxMD
  4. 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
  5. Kaman L. Management of Esophageal Perforation in Adults. Gastroenterology Research. 2011 . doi: 10.4021/gr263w . | Open in Read by QxMD
  6. 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
  7. 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
  8. 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
  9. Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol. 2017; 112 (7): p.988-1013. doi: 10.1038/ajg.2017.154 . | Open in Read by QxMD
  10. 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
  11. 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
  12. Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician.. 2015; 91 (4): p.236-242.
  13. 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
  14. D Jeffrey. Acute Pancreatitis. AAFP. 2014 .
  15. 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
  16. 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.
  17. 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.
  18. 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
  19. 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
  20. 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
  21. Mallory Weiss Syndrome. https://www.ncbi.nlm.nih.gov/books/NBK538190/. Updated: November 24, 2019. Accessed: January 6, 2020.
  22. Cayley WE Jr. Diagnosing the cause of chest pain.. Am Fam Physician. 2005; 72 (10): p.2012-21.
  23. 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
  24. 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
  25. 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
  26. 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
  27. 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
  28. Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003; 349 (7): p.684-690. doi: 10.1056/nejmra022643 . | Open in Read by QxMD
  29. Snyder MJ, Bepko J, White M. Acute pericarditis: diagnosis and management.. Am Fam Physician. 2014; 89 (7): p.553-60.
  30. 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
  31. 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
  32. 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
  33. 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
  34. 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
  35. 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
  36. 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
  37. 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
  38. 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
  39. 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
  40. 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
  41. 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
  42. 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
  43. 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
  44. 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
  45. 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.
  46. 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
  47. 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
  48. Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment.. Am Fam Physician. 2009; 80 (6): p.617-20.
  49. 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
  50. 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.
  51. 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
  52. 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
  53. 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
  54. 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
  55. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  56. 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
  57. 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.
  58. 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
  59. O'Connel TX, Movalia M. Brochert's Crush Step 2: The Ultimate USMLE Step 2 Review. Saunders ; 2012
  60. 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.
  61. 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
  62. 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
  63. 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
  64. 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
  65. 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
  66. 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
  67. 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
  68. 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
  69. 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
  70. 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
  71. 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
  72. 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

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