Chest pain: an overview
Chest pain is a symptom, not a diagnosis, spanning cardiac, vascular, pulmonary, gastrointestinal, musculoskeletal, and psychiatric causes. The essential task is separating four do-not-miss diagnoses, acute coronary syndrome, aortic dissection, pulmonary embolism, and tension pneumothorax, from benign mimics with a structured history, an ECG within 10 minutes, and serial troponin, treating suspected acute coronary syndrome empirically with aspirin and nitroglycerin while the workup proceeds.
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What this article covers
- Overview
Definition and mechanism: chest pain is a presenting symptom, not a diagnosis, discomfort from the neck to the epigastrium from cardiac, vascular, pulmonary, gastrointestinal, musculoskeletal, or…
- Epidemiology
Volume and outcome: chest pain is among the most common reasons for an emergency department visit, and most patients are ultimately found to have a noncardiac cause.
- Risk factors
Atherosclerotic: hypertension, diabetes, hyperlipidemia, smoking, family history of premature coronary disease (men under 55, women under 65), and abdominal obesity raise the odds of an ischemic cause.
- Pathophysiology
Ischemic pain: obstructive coronary atherosclerosis, typically over 70% luminal stenosis for stable angina, or acute plaque rupture with thrombus for ACS, drops myocardial oxygen supply below demand…
- Clinical features
Typical angina, formally defined: substernal discomfort, provoked by exertion or emotional stress, and relieved by rest or nitroglycerin within minutes; all 3 features defines typical angina, 2 of 3 atypical, and 1 or none noncardiac.
- Differential diagnosis
ACS versus stable angina: both cause exertional pressure, but ACS pain occurs at rest, is new-onset, or is more severe and longer-lasting, and does not fully resolve with rest.
- Diagnosis
What establishes the diagnosis: no single test diagnoses "chest pain"; the cause is established by criteria specific to that entity, ST elevation for STEMI, a troponin above the 99th percentile upper…
- Management
First, triage and stabilize: intravenous access, cardiac monitoring, and pulse oximetry for any do-not-miss feature, instability, or pulse or pressure asymmetry, before the workup proceeds further.
- Complications
Missed ACS, dissection, or embolism: unrecognized infarction leads to recurrent infarction, cardiogenic shock, and papillary muscle rupture within days; an unrepaired type A dissection carries…
- Prognosis
Risk-stratified and time-dependent outcomes: a TIMI score under 2 or a GRACE score under 109 predicts a low 14-day risk of death, reinfarction, or urgent revascularization; infarct size and mortality…
- Prevention
Atherosclerotic risk reduction: blood pressure control, an LDL cholesterol target guided by cardiovascular risk, smoking cessation, and diabetes control lower future ischemic chest pain incidence…
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Related articles
- ST-elevation myocardial infarction (STEMI)
ST-elevation myocardial infarction is acute transmural myocardial ischemia from complete coronary occlusion, diagnosed by ischemic symptoms with diagnostic ST-segment elevation and a rising troponin. It is a time-critical emergency in which immediate reperfusion, primary PCI within 90 minutes or fibrinolysis when PCI is unavailable, plus antiplatelet and anticoagulant therapy, determines survival.
- Non-ST-elevation myocardial infarction (NSTEMI)
Non-ST-elevation myocardial infarction is acute myocardial injury from partial or intermittent coronary occlusion, diagnosed by ischemic symptoms and a rising troponin without diagnostic ST elevation. Management is antiplatelet and anticoagulant therapy with risk stratification (TIMI or GRACE) guiding the timing of an invasive coronary strategy.
- Unstable angina
Unstable angina is acute myocardial ischemia from a non-occlusive coronary thrombus causing rest, new, or crescendo angina without a troponin rise, placing it on the acute coronary syndrome spectrum just short of NSTEMI. Diagnosis is clinical with ischemic ECG changes and negative serial troponins, and management mirrors NSTE-ACS with antithrombotic therapy and risk-guided angiography.
- Aortic dissection
Aortic dissection is a tear in the aortic intima allowing blood to split the media, creating a false lumen, and is a surgical emergency. Type A (ascending) dissection needs emergency surgery, while type B (descending) is usually managed medically with rapid heart-rate and blood-pressure control; the priority is impulse control with a beta-blocker first.
- Acute pericarditis
Acute pericarditis is inflammation of the pericardium, most often viral or idiopathic, presenting with pleuritic chest pain relieved by sitting forward, a pericardial friction rub, and diffuse ST elevation with PR depression. Treatment is an NSAID plus colchicine, and the main hazards are effusion, tamponade, and recurrence.
- Pulmonary embolism
Pulmonary embolism is thrombus, usually from a lower-extremity deep vein thrombosis, obstructing the pulmonary arterial circulation and causing V/Q mismatch, right ventricular strain, and hypoxemia. Diagnosis follows Wells criteria (with PERC in low-risk patients) to sequence D-dimer, CT pulmonary angiography, and V/Q scanning, and management is risk-stratified anticoagulation escalating to thrombolysis or embolectomy for hemodynamic instability.
- Gastroesophageal reflux disease (GERD)
GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.
- Panic disorder
Panic disorder is an anxiety disorder defined by recurrent, unexpected panic attacks, discrete surges of fear that peak within 10 minutes with 4 or more characteristic symptoms, followed by at least 1 month of persistent worry about further attacks, worry about their consequences, or a maladaptive behavior change. Medical mimics such as acute coronary syndrome, pulmonary embolism, arrhythmia, hyperthyroidism, pheochromocytoma, and hypoglycemia must be excluded first. First-line treatment is a selective serotonin reuptake inhibitor such as sertraline, started low and titrated slowly, combined with cognitive behavioral therapy; benzodiazepines are reserved for short-term acute control.