Chest pain

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]

• All patients
  • ABCDE survey
  • Focused clinical evaluation
  • 12-lead ECG within 10 minutes of patient arrival
  • IV access
  • Routine diagnostic studies (e.g., troponin, CXR)
  • Identify and treat the underlying cause.
• Red flags for chest pain present: i.e., high risk of critical causes of chest pain
  • Perform POCUS (e.g., eFAST, focused cardiac ultrasound, lung POCUS). ^[1][4]
  • Begin time-sensitive management (e.g., activate cath lab for STEMI).
  • Obtain definitive imaging (e.g., CTA chest for TAA).
  • Consider urgent specialty consult and critical care unit admission.
• Red flags for chest pain absent: i.e., low risk of critical causes of chest pain
  • Consider additional studies (see “Diagnostics for chest pain”).
  • Use risk stratification tools, e.g.:
    • HEART score for risk stratification for ACS (See also “Decision pathway for possible NSTE-ACS.”)
    • Wells score for PE (See also “PE diagnostics.”)
  • Consider inpatient admission if the diagnosis is uncertain or clinical suspicion of a critical cause persists.

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]

• Symptoms
  • Sudden onset
  • Exertional chest pain
  • Substernal or left-sided pain
  • Radiation to the left arm, jaw, and/or back
  • Quality of chest pain: crushing, pressure , tearing, and/or ripping
  • Associated symptoms: shortness of breath, diaphoresis, nausea, and/or vomiting
• Signs
  • Vital sign abnormalities (e.g., hypoxia, hypotension)
  • Pulsus paradoxus
  • Difference of > 20 mm Hg in systolic blood pressure between arms ^[5]
  • New murmur
  • Chest wall crepitus
  • Distant heart sounds

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]

• Acute coronary syndrome (i.e., STEMI, NSTEMI, unstable angina)
• Pulmonary embolism
• Aortic dissection
• Tension pneumothorax
• Cardiac tamponade
• Esophageal rupture

Cardiac

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

• Acute coronary syndrome
• Cardiac tamponade
• Pericarditis
• Myocarditis
• Endocarditis
• Takotsubo cardiomyopathy
• Aortic dissection
• Valvular disease (e.g., aortic stenosis, mitral regurgitation, aortic regurgitation)
• Stable angina
• Vasospastic angina
• Hypertensive crisis
• Heart failure exacerbation
• Postcardiac injury syndrome
• Postmyocardial infarction syndrome
• Postpericardiotomy syndrome

Pulmonary

• Pulmonary embolism
• Tension pneumothorax
• Pneumothorax
• Pneumonia
• Bronchitis
• Asthma exacerbation
• COPD exacerbation
• Hemothorax
• Pulmonary edema
• Pleural effusion
• Pleuritis
  • Fibrinous pleuritis
  • Rheumatoid pleuritis
  • Lupus pleuritis
• Pulmonary sarcoidosis
• Lung contusion
• Pulmonary infarct
• Lung abscess
• Lung cancer

Musculoskeletal

• Costochondritis
• Chest trauma
• Chest wall pain
• Rib fracture
• Rib contusion
• Osteoarthritis of the sternoclavicular or manubriosternal joint
• Osteoarthritis of the shoulder joints
• Slipping rib syndrome
• Tietze syndrome
• Overuse myalgia
• Thoracic outlet syndrome

Gastrointestinal

• Esophageal perforation
• Boerhaave syndrome
• Mallory-Weiss syndrome
• Gastroesophageal reflux disease
• Acute erosive gastritis
• Acute erosive esophagitis
• Eosinophilic esophagitis
• Dyspepsia
• Peptic ulcer disease
• Esophageal motility disorder
  • Achalasia
  • Distal esophageal spasm
  • Hypercontractile esophagus
• Esophageal hypersensitivity
• Sliding hiatal hernia
• Biliary colic
• Cholelithiasis
• Choledocholithiasis
• Cholecystitis
• Acute pancreatitis
• Acute hepatitis
• Liver abscess
• Fitz-Hugh-Curtis syndrome

Renal

• Renal infarct
• Renal capsular hematoma

Dermatological

• Herpes zoster
• Postherpetic neuralgia

Hematologic/Oncologic

• Acute pain crisis
• Acute chest syndrome
• Malignancy
• Malignant pleural effusion
• Splenic infarct

Rheumatologic

• Rheumatoid arthritis
• SLE
• Fibromyalgia

Psychiatric

• Functional chest pain
• Generalized anxiety disorder
• Panic disorder, panic attack
• Major depressive disorder
• Somatic symptom disorder
• Substance use disorders (e.g., cocaine, methamphetamines, alcohol)
• Illness anxiety disorder

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.

ECG

• Obtain 12-lead ECG as soon as possible.
• Evaluate for:
  • STEMI and STEMI equivalents
  • Conduction abnormalities, e.g., tachyarrhythmias, heart block
  • Findings of systemic disorders and anatomic abnormalities
• See “Life-threatening ECG findings” for details and examples.

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

• Troponin ^[6]
• CBC
• BMP

Additional investigations

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

• BNP or NT-proBNP
• D-dimer
• Lactate
• Preoperative studies: PT, PTT, type and screen
• Abdominal studies: LFTs , lipase, amylase
• Acute phase reactants: ESR, CRP , procalcitonin
• Cultures: blood cultures, sputum cultures
• Acute viral hepatitis panel
• Respiratory viral panel
• Urine toxicology screen

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:

• Portable CXR (anteroposterior view)
• POCUS ^[1][4]
  • Focused cardiac ultrasound
  • Lung POCUS
  • eFAST
  • Biliary POCUS
  • POCUS for suspected AAA
• Lung ultrasound
• Portable abdominal x-ray (upright)
• Echocardiography (e.g., TTE, TEE)

Additional investigations

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

• CXR (posteroanterior and lateral; rib series if there is concern for rib fracture)
• Abdominal series x-ray
• CT chest (with IV contrast)
• CTA chest (pulmonary embolism protocol)
• CTA chest, abdomen, and pelvis (to evaluate the aorta)
• Ultrasound right upper quadrant
• Lower extremity venous ultrasound
• V/Q scan

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

Costochondritis ^[51]

• Definition: an inflammation of rib cage cartilage (esp. of the costochondral and costosternal junction)
• Etiology: often occurs as a result of excessive exercise or minor chest wall trauma
• Clinical features
  • Sharp, well-localized pain that is reproducible on palpation of costal cartilage
  • History of recent exercise/exertion/chest wall trauma
• Diagnostics
  • Clinical diagnosis ^[51]
  • CXR: normal
• Treatment
  • Pain management
    • Acetaminophen
    • NSAIDs (e.g., naproxen, ibuprofen )
  • Supportive care
    • Physical therapy (i.e., stretching exercises)
    • Reduction of activities that provoke symptoms
    • Cough suppressants
    • Heat or ice packs

Herpes zoster ^[52][53]

• Clinical features
  • Severe burning or throbbing pain
  • Thoracic dermatomes are most commonly affected
  • Maculopapular rash that develops into a vesicular rash in a dermatomal distribution
  • Immunocompromised status
• Diagnostics
  • Clinical diagnosis
  • PCR of vesicle fluid positive for varicella-zoster virus DNA ^[53]
• Treatment
  • Antivirals (See the acute management checklist for herpes zoster.)

Functional chest pain ^[35][54]

• Clinical features
  • Retrosternal chest pain or discomfort
  • No associated esophageal symptoms (e.g., no heartburn, dysphagia)
• Diagnostics
  • Diagnosis of exclusion
  • Rome IV criteria for functional chest pain
• Treatment
  • Reassure the patient.
  • Referral to psychologist ^[54]
  • Consider initiating medical therapy with one of the following:
    • TCA (e.g., amitriptyline)
    • SARI (e.g., trazodone)
    • SSRI (e.g., sertraline)
    • SNRI (e.g., venlafaxine)

• One-Minute Telegram 51-2022-1/3: Is all chest pain created equal?

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