Chest Pain

Last Updated: 08/22/2023

#Chest Pain


  • Onset: *** acute/gradual, preceding events - exertion, trauma, drug use, post-prandial
  • Location: *** substernal, left/right, point
  • Quality: *** sharp, dull, pressure, burning, stabbing
  • Radiation: *** neck, jaw, shoulders, arms
  • Timing: *** constant, intermittent
  • Severity: *** 
  • Better/Worse: *** palpation, positioning, rest, nitroglycerin, other meds, breathing, exertion
  • Associated Symptoms: *** SOB, n/v, sweating, dizziness, palpitations, fever, cough
  • Notable PMH: *** CAD, CHF, HTN, T2DM, HLD, PAD, smoking
  • Red Flags: *** h/o ischemia, clotting, recent procedure; fevers, substernal, with exertion, crushing, radiate to arms, SOB, dysphagia
  • DDx: *** ACS, dissection, PE, PTX, esophageal, costochondritis, GERD, pill, vasospastic, panic disorder

Emergent - Cardiac

  • ACS - substernal, radiate to arms, jaw, exertion, relieved by rest - trop, EKG
  • Aortic Dissection - sudden, severe, radiate to back, HTN - CTA, manage BP
  • Takotsubo - presents similar to ACS - TTE
  • Tamponade / Pericarditis - TTE

Emergent - Pulmonary

  • PE - sharp/stabbing, pleuritic, CTPE
  • Pneumothorax - CXR
  • Pneumonia- CXR - start abx

Emergent - Esophageal

  • Rupture (Boerhaave) - after vomiting, procedure - CT → upper endoscopy
  • Impaction - ingestion in foreign objects - CT → upper endoscopy


  • Costocondritis, rib fracture/contusion - with palpation - NSAIDs
  • Zoster - evaluate skin - acyclovir
  • GERD, esophageal spasm, PUD - associated with meals - PPI
  • Pill Esophagitis - iron tablets, potassium, NSAIDs, tylenol, abx
  • Vasospastic “Prinzmetal” Angina - worse with smoking, EtOH - avoid trigger, CCB
  • Biliary Colic, Hepatitis - RUQUS, LFTs
  • Malignancy - CT/MRI
  • Psychiatric - GAD, Panic Disorder, Somatic Symptom Disorder


  • Send to ED if concerned about an emergent cause of pain (ACS, dissection, PE, PTX)
  • Workup: trop, NT-proBNP, EKG, CXR → CTPE, Echo, consider stress testing if seems ischemic
  • Medication: *** nitroglycerin, NSAIDs, PPI

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Patient Guidance and Information

New Chest Pain

Chest pain can be caused by many different conditions, some of which can be serious. Based on our discussion, we are most concerned about *** and have started investigating potential causes. It's important to remain vigilant - if your pain becomes severe, is associated with shortness of breath, sweating, nausea, vomiting, dizziness, or fainting, or if you notice a sudden change in your symptoms, please seek immediate medical attention. These could be signs of a more serious condition, like a heart attack.

In the meantime, please remember to take your medications as prescribed, and avoid any known triggers for your chest pain. It is important to avoid tobacco use and excessive alcohol, maintain a balanced diet, and engage in regular physical activity as your symptoms allow. 

If you have any questions or concerns, please do not hesitate to contact us via this portal or by phone.

If You Remember Nothing Else

It's crucial to first rule out life-threatening causes, particularly acute coronary syndrome (ACS). A basic workup should always include trop, NT-proBNP, EKG, and a CXR. For low-risk patients, a thoughtful differential diagnosis is key - think beyond the heart to pulmonary, gastrointestinal, musculoskeletal, and psychological causes. Tailor your workup accordingly; chest pain is a symptom, not a diagnosis, and clinical judgment is paramount.

Clinical Pearls

Characteristics and Duration of Chest Pain:

  • Brief episodes of pain (<5 minutes) are less likely to be cardiac in origin and could suggest conditions like costochondritis or esophageal spasm.
  • Pain lasting longer than 20 minutes is more suggestive of cardiac etiology.

Differential Diagnosis and Clues:

  • GERD can cause burning chest pain that can be very difficult to distinguish from cardiac chest pain. Trial of a proton pump inhibitor or response to antacids may provide clues.
  • Elderly patients, women, and those with diabetes may not present with classic symptoms of cardiac chest pain and may instead have fatigue, shortness of breath, or other non-specific symptoms.

Diagnostic Tools and Interpretation:

  • History alone cannot reliably rule in or rule out ACS.
  • Troponin is highly sensitive but not specific for ACS and needs to be trended out as it may commonly lag the onset of chest pain symptoms.
  • In ACS, creatine kinase (CK) will remain high for 3-4 days and troponin will stay high for 7-10 days; thus CK is the more reliable test for recurrent ischemia.
  • The most useful scores for evaluation of chest pain in the ED are the TIMI and HEART scores.
  • If you are concerned that a patient is having active ischemia, keep the EKG attached and get a new reading every 5-10 minutes - you may be able to catch dynamic changes.

Medications and Treatment:

  • Ranolazine is an anti-anginal agent that doesn't affect heart rate or blood pressure and can thus be useful in patients who can't tolerate other anti-anginals; mechanism involves shifting myocardial cell metabolism from fatty acids to glucose, which requires less oxygen
  • Nitroglycerin provides rapid relief for angina by causing venous and arterial dilation, reducing myocardial oxygen demand - they should be avoided in inferior MI involving RV because the RV is preload-dependent, meaning it relies on adequate venous return for optimal function and vasodilation can reduce preload and lead to a dangerous drop in BP
  • Calcium channel blockers like verapamil, diltiazem, or nifedipine are first-line for coronary artery spasm (Prinzmetal Angina) - they act primary via dilation

Stress Tests:

  • Exercise EKG Stress Test (Treadmill Test) - exercise on a treadmill or bicycle to increase HR and BP while monitoring EKG to look for evidence of ischemia; refer if patients can exercise and have baseline EKG
  • Stress Echocardiography - echo is taken at rest and immediately after exercise; best for patients with known CAD, baseline EKG not normal
  • Nuclear Stress Test (Perfusion Imaging) - radioactive dye injected and images taken before and after exercise or chemical stress (below); patients with a high risk of CAD, prior inconclusive stress tests, those who can’t exercise
  • Pharmacologic Stress Test - adenosine or dobutamine (most commonly) given to simulate exercise of the heart, and then an echo or nuclear scan is performed; ideal for patients who can’t exercise or with baseline EKG abnormalities
  • Contraindications to cardiac stress testing: Absolute - acute MI or UA, arrhythmia, PE, severe AS, myocarditis/pericarditis, dissection; Relative - known left main disease, SBP >200, moderate valvular stenosis, hypertrophic cardiomyopathy, 2nd (Type 2) or 3rd degree AV block
  • Exercise stress testing (e.g., treadmill or bicycle) is preferred over pharmacologic stress because it provides information on exercise tolerance and can reveal exercise-induced arrhythmias.
  • Achieving at least 85% of the maximum predicted heart rate (220 minus age) is generally required for an exercise stress test to be considered diagnostic
  • During a stress test, symptoms like dyspnea, dizziness, or chest pain, as well as a drop in blood pressure, can be as significant as ECG changes
  • Stress tests can have false positives, especially in low-risk populations or in women with a low pre-test probability of coronary artery disease.
  • In general, beta-blockers, calcium channel blockers, and nitrates can affect the results of stress tests and are generally held before a test
  • Caffeine should be avoided in pharmacologic stress tests using adenosine or dipyridamole, as it blocks adenosine receptors
  • In general, dobutamine should be avoided in patients with severe asthma, as it can provoke bronchospasm

Trials and Literature

Other Resources