Stethopedia | Approach

Approach to

Chest Pain

ECG in 10 min; act on shock, STEMI or a bedside red flag, then sort by system. HEART 0–3 still needs serial negative hs-troponin. STEMI <12 h: PCI ≤120 min from FMC, else lytics then transfer.

  1. Acute chest pain or an anginal equivalent (dyspnea, jaw, arm, epigastric)
  2. 12-lead ECG within 10 min vs prior; BP both arms; hs-troponin 0 and 1–3 h; CXR1,2,12
  3. Shock, STEMI or a bedside red flag?

Emergency: cath lab, decompress, echo or CTA2,6,11

  • New STE ≥1 mm ×2 leads (V2–3: ≥1.5–2.5 mm)4
  • Posterior STEMI; Sgarbossa+ LBBB/paced4,12
  • Hypotension, hypoxemia, VT/VF
  • Tearing pain + pulse deficit/BP Δ >20 mmHg6,12
  • Absent breath sounds, tracheal shift, ↓BP
  • ↑JVP, muffled sounds, pulsus >10 mmHg12

→ Cath lab: STEMI, unstable ACS; decompress; echo; CTA/TEE aorta

If not: which system?

CausesCluesWorkupManagement

Myocardial ischemia

  • STEMI
  • NSTEMI, unstable angina
  • Angina, AS, HCM, spasm, Takotsubo
  • Radiates to both arms (LR 2.6)3
  • Prior abnormal stress test (LR 3.1)3
  • ST depression on ECG (LR 5.3)3
  • hs-Tn >99th %ile + rise/fall at 0, 1–3 h2,4
  • HEART score if not ruled in or out5
  • CCTA or stress test if intermediate1
  • ASA 162–325 mg chewed; DAPT, heparin2
  • STEMI <12 h: PCI ≤120 min, else lytics2,11
  • NSTE-ACS: cath <24 h if GRACE >1402

Aortic & pericardial

  • Acute aortic syndrome
  • Cardiac tamponade
  • Pericarditis, myopericarditis
  • Abrupt severe or tearing pain to back6
  • Sharp, pleuritic, better sitting forward10
  • Friction rub; diffuse STE, PR depression10
  • Out if ADD-RS ≤1 + D-dimer <500 µg/L7
  • Otherwise CT angiography of the aorta6
  • Echo: effusion, tamponade, AR6,10
  • AAS: IV β-blocker; HR 60–80, SBP <120 mmHg6
  • Type A: emergency surgery; no lytics6
  • Pericarditis: NSAID + colchicine10

Pulmonary

  • Pulmonary embolism
  • Tension pneumothorax
  • Pneumonia, pleuritis
  • Pleuritic pain, dyspnea, hypoxemia8
  • Leg swelling; cancer, surgery, immobile8
  • Fever, cough, crackles, dullness
  • Wells + PERC, then D-dimer or CTPA8,9
  • CXR: pneumothorax, consolidation
  • Bedside echo: RV strain8
  • PE: anticoagulate; lyse if shock8
  • Tension PTX: needle, then chest tube12
  • Pneumonia: antibiotics by severity

GI & chest wall

  • Esophageal rupture
  • GERD, spasm, PUD, biliary, pancreatitis
  • Costochondritis, zoster, panic
  • Focal tenderness reproduces the pain3
  • Burning, meal-related, epigastric
  • Pain after retching; neck crepitus
  • Only once ACS is reasonably excluded1
  • Lipase, LFTs; RUQ ultrasound if biliary
  • CT with oral contrast if rupture suspected
  • GERD: PPI trial
  • Chest wall: NSAID, reassurance
  • Rupture: NPO, antibiotics, surgery

Can't-miss cause Superscripts link to the references below.

References

  1. 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. Circulation. 2021;144:e368–e454. PubMed 34709879
  2. Rao SV, O'Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes. Circulation. 2025;151:e771–e862. PubMed 40014670
  3. Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does this patient with chest pain have acute coronary syndrome? The Rational Clinical Examination systematic review. JAMA. 2015;314:1955–1965. PubMed 26547467
  4. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol. 2018;72:2231–2264. PubMed 30153967
  5. Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168:2153–2158. PubMed 23465250
  6. Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease. Circulation. 2022;146:e334–e482. PubMed 36322642
  7. Nazerian P, Mueller C, Soeiro AM, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED prospective multicenter study. Circulation. 2018;137:250–258. PubMed 29030346
  8. Writing Committee Members; Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for the evaluation and management of acute pulmonary embolism in adults. Circulation. 2026;153:e977–e1051. PubMed 41712677
  9. Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6:772–780. PubMed 18318689
  10. Schulz-Menger J, Collini V, Gröschel J, et al. 2025 ESC guidelines for the management of myocarditis and pericarditis. Eur Heart J. 2025;46:3952–4041. PubMed 40878297
  11. Wong GC, Welsford M, Ainsworth C, et al. 2019 CCS/CAIC guidelines on the acute management of ST-elevation myocardial infarction: focused update on regionalization and reperfusion. Can J Cardiol. 2019;35:107–132. PubMed 30760415
  12. Gay E, Levy N, eds. Chest Pain; Acute Coronary Syndrome; Aortic Disease; Respiratory Distress. In: Department of Medicine Housestaff Manual, 30th ed. 2024:13–14, 32, 43.

For education only; not a substitute for clinical judgment or local protocols. Where sources differ, the flowchart follows the current guideline.

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