Approach to Acute Chest Pain: What Not to Miss

Chest pain is one of the most common reasons patients come to the emergency department, and one of the most common topics in medical exams. Most chest pain is not dangerous, but a small number of causes can kill within hours. The aim of a good approach is simple: recognise the life-threatening causes first, then work through the rest.

The "must not miss" causes

Acute coronary syndrome (ST-elevation myocardial infarction, non-ST-elevation myocardial infarction and unstable angina)
Aortic dissection
Pulmonary embolism
Tension pneumothorax
Oesophageal rupture
Cardiac tamponade

First minutes: assess and stabilise

An unwell patient with chest pain needs an ABCDE assessment and immediate monitoring: oxygen saturation, heart rate, blood pressure (in both arms if dissection is possible), and a 12-lead ECG within 10 minutes of arrival. Gain IV access, take bloods and call for senior help early if the patient is unstable.

Use the history to narrow it down

Explore the pain using SOCRATES (site, onset, character, radiation, associated symptoms, time course, exacerbating and relieving factors, severity). Typical clues include:

Cardiac ischaemia: central, heavy or tight pain, often radiating to the arm, jaw or neck, with sweating, nausea or breathlessness. Women, older people and people with diabetes may have atypical symptoms.
Aortic dissection: sudden, severe, "tearing" pain, often radiating to the back.
Pulmonary embolism: pleuritic pain with sudden breathlessness, sometimes haemoptysis, often with risk factors such as recent surgery, immobility or cancer.
Pneumothorax: sudden pleuritic pain and breathlessness, for example in a tall young man or a patient with lung disease.
Pericarditis: sharp pain, worse lying flat and better sitting forward.
Oesophageal rupture: severe pain after forceful vomiting.

Also ask about cardiovascular risk factors: smoking, diabetes, hypertension, high cholesterol, family history and previous heart disease.

Examination clues

Unequal arm pulses or blood pressures, or a new aortic regurgitation murmur → think dissection.
Absent breath sounds with tracheal deviation and shock → think tension pneumothorax.
Raised jugular venous pressure, low blood pressure and quiet heart sounds → think tamponade.
Pericardial rub → pericarditis.
Calf swelling → think deep vein thrombosis and pulmonary embolism.
Chest wall tenderness alone does not exclude a serious cause.

Key investigations

ECG — repeat it if the pain continues or changes.
Cardiac troponin — usually measured on arrival and repeated according to local high-sensitivity troponin protocols.
Chest X-ray — pneumothorax, consolidation, widened mediastinum.
Blood tests — full blood count, kidney function, electrolytes, glucose; D-dimer only in patients with a low clinical probability of pulmonary embolism.
Imaging guided by suspicion — CT pulmonary angiography for pulmonary embolism, CT aortography for dissection, echocardiography for tamponade or wall motion abnormalities.

Principles of management

Treatment depends on the cause and must follow current local guidelines and senior advice. For example, ST-elevation myocardial infarction needs urgent reperfusion; tension pneumothorax needs immediate decompression; and suspected aortic dissection needs blood pressure control and urgent specialist review — antiplatelet and anticoagulant drugs must not be given until dissection has been excluded.

Exam tips

Always say "ABCDE" and "ECG within 10 minutes" first.
List the life-threatening causes before the common benign ones such as musculoskeletal pain or reflux.
Link each differential to a specific clue from the history or examination.

This article is a study summary for exams. Real patients with chest pain need urgent assessment by a qualified doctor following local protocols. For more detail, see the cardiovascular section of our Medicine Companion and our article Reading an ECG: A Systematic 8-Step Approach.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

A 60-year-old presents with central crushing chest pain. What is the first investigation?
1. Exercise tolerance test
2. 12-lead ECG within 10 minutes
3. Echocardiogram
4. Chest X-ray
5. CT pulmonary angiogram
Show answer
Answer: B. 12-lead ECG within 10 minutes
An ECG within 10 minutes of arrival identifies STEMI and other urgent diagnoses.
Sudden tearing chest pain radiating to the back with unequal arm blood pressures suggests:
1. Reflux
2. Pericarditis
3. Aortic dissection
4. Costochondritis
5. Pulmonary embolism
Show answer
Answer: C. Aortic dissection
Tearing pain to the back and blood pressure difference between the arms are classic of aortic dissection.
Pain that is sharp, worse lying flat and better sitting forward suggests:
1. Myocardial infarction
2. Aortic dissection
3. Oesophageal rupture
4. Pneumothorax
5. Pericarditis
Show answer
Answer: E. Pericarditis
Positional, pleuritic-type pain relieved by sitting forward is typical of pericarditis.
In suspected aortic dissection, which treatment must be avoided until dissection is excluded?
1. IV access
2. Oxygen if hypoxic
3. Blood pressure control
4. Analgesia
5. Antiplatelet and anticoagulant drugs
Show answer
Answer: E. Antiplatelet and anticoagulant drugs
Antiplatelets and anticoagulants can be catastrophic in dissection; exclude it first.
Severe chest pain after forceful vomiting should raise concern for:
1. Panic attack
2. Gallstones
3. Mallory–Weiss tear only
4. Oesophageal rupture (Boerhaave syndrome)
5. Angina
Show answer
Answer: D. Oesophageal rupture (Boerhaave syndrome)
Severe pain after forceful vomiting suggests oesophageal rupture, a life-threatening emergency.

Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.

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