Acute chest pain

See Acute coronary syndrome (main) for ACS-specific workup and risk stratification; see Chest pain (peds) for pediatric patients.

Background

Chest pain accounts for approximately 6-8% of all ED visits^[1]^[2]
The primary ED goal is to rapidly identify and treat immediately life-threatening causes ("the big 5"):
- Acute coronary syndrome (ACS)
- Pulmonary embolism (PE)
- Aortic dissection
- Tension pneumothorax
- Esophageal perforation (Boerhaave syndrome)
Most chest pain in the ED is ultimately non-cardiac, but the evaluation is driven by the need to exclude dangerous etiologies

Clinical Features

Risk of Acute Coronary Syndrome

Clinical factors that increase likelihood of ACS/AMI:^[3]^[4]

Chest pain radiating to both arms > R arm > L arm
Chest pain associated with diaphoresis
Chest pain associated with nausea OR vomiting
Chest pain with exertion that is improved with rest

Clinical factors that decrease likelihood of ACS/AMI:^[5]

Pleuritic chest pain
Positional chest pain
Sharp, stabbing chest pain
Chest pain reproducible with palpation

Gender differences in ACS

Women with ACS:
- Less likely to be treated with guideline-directed medical therapies^[6]
- Less likely to undergo cardiac catheterization^[6]
- Less likely to receive timely reperfusion therapy^[6]
- More likely to report fatigue, dyspnea, indigestion, nausea or vomiting, palpitations, or weakness,^[6] although some studies have found fewer differences in presentation^[7]
More likely to delay presentation^[6]
Men with ACS:
- More likely to report central chest pain

Factors associated with delayed presentation^[6]

Female sex
Older age
Black or Hispanic race
Low educational achievement
Low socioeconomic status
Key historical features to assess:
- Quality: crushing/pressure (ACS), tearing/ripping (dissection), pleuritic/sharp (PE, pericarditis, pneumothorax)
- Radiation: jaw/arm (ACS), back (dissection), shoulder (pericarditis)
- Onset: sudden (PE, dissection, pneumothorax) vs gradual (ACS, musculoskeletal)
- Associated symptoms: diaphoresis, dyspnea, nausea/vomiting, syncope
- Risk factors: cardiac history, DVT/PE risk factors, cocaine use, connective tissue disease, recent procedure
Red flags:
- Hemodynamic instability
- New ECG changes (ST elevation/depression, new LBBB)
- Unequal blood pressures or pulses (aortic dissection)
- Tracheal deviation, absent breath sounds (tension pneumothorax)
- Subcutaneous emphysema (pneumomediastinum, esophageal perforation)

Differential Diagnosis

Chest pain

Critical

Acute coronary syndromes (ACS)
Aortic dissection
Cardiac tamponade
Coronary artery dissection
Esophageal perforation (Boerhhaave's syndrome)
Pulmonary embolism
Tension pneumothorax

Emergent

Nonemergent

Evaluation

Workup

All patients:
- ECG - within 10 minutes of arrival; repeat if symptoms change or initially nondiagnostic
- CXR
- Vital signs including bilateral blood pressures if dissection suspected
Moderate-to-high risk or concerning features:
- Troponin - serial troponins (0h and 1-3h with high-sensitivity assay; 0h and 3-6h with conventional assay)
- CBC, BMP
- Consider coagulation studies
Additional testing based on suspicion:
- D-dimer or CT-PA - if PE suspected (use validated pretest probability tools: Wells score, PERC rule, YEARS algorithm)
- CT angiography of chest/abdomen/pelvis - if aortic dissection suspected
- BNP/NT-proBNP - if CHF suspected
- Point-of-care echo - for pericardial effusion, RV strain, wall motion abnormalities, aortic root dilation

Risk Stratification

HEART Score: Validated tool for risk stratification in undifferentiated chest pain
- Score 0-3: Low risk; consider early discharge
- Score 4-6: Moderate risk; admission/observation with serial troponins
- Score 7-10: High risk; admission with cardiology consultation
Wells score: For pretest probability of PE
PERC rule: If low pretest probability, PERC can exclude PE without D-dimer

Management

Treat based on underlying cause:
- ACS: ASA, anticoagulation, cardiology consultation; PCI for STEMI (see ST-segment elevation myocardial infarction)
- PE: Anticoagulation; thrombolytics for massive PE (see Pulmonary embolism)
- Aortic dissection: HR and BP control; emergent surgical consultation for Type A (see Nontraumatic thoracic aortic dissection)
- Tension pneumothorax: Needle decompression followed by chest tube
- Pericardial tamponade: Pericardiocentesis
Pain control: Avoid NSAIDs if ACS suspected; nitroglycerin for ischemic pain (avoid in RV infarct, recent PDE5 inhibitor use, hypotension)

Disposition

Admit to ICU/monitored bed:
- STEMI, unstable ACS, hemodynamically significant PE, aortic dissection, pericardial tamponade
Admit/observe:
- Moderate HEART score with pending serial troponins
- NSTEMI awaiting cardiology evaluation
Discharge:
- Low HEART score (0-3) with negative serial troponins
- Clear non-cardiac cause identified (e.g., musculoskeletal, GERD)
- PE ruled out with validated approach
- Arrange appropriate follow-up (PCP within 72 hours for intermediate-risk patients)

Calculators

HEART Score

HEART Score Calculator
Criteria	Select One
History	Slightly suspicious (0)	Moderately suspicious (+1)	Highly suspicious (+2)
EKG	Normal (0)	Non-specific repolarization disturbance (+1)	Significant ST deviation (+2)
Age	<45 (0)	45–64 (+1)	≥65 (+2)
Risk Factors HTN, hypercholesterolemia, DM, obesity (BMI >30), smoking, family hx CVD, or hx atherosclerotic disease	No known risk factors (0)	1–2 risk factors (+1)	≥3 risk factors or hx atherosclerotic disease (+2)
Initial Troponin	≤normal limit (0)	1–3× normal limit (+1)	>3× normal limit (+2)
HEART Score	/ 10

Interpretation
0–3	Low Risk — 0.9–1.7% risk of MACE. Consider discharge with outpatient follow-up.
4–6	Moderate Risk — 12–16.6% risk of MACE. Consider admission for observation and further workup.
7–10	High Risk — 50–65% risk of MACE. Consider early invasive measures (cardiology consult, catheterization).

References
Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-196. PMID 18665203. Backus BE, Six AJ, Kelder JC, et al. Prospective validation of the HEART score for chest pain patients. Int J Cardiol. 2013;168(3):2153-2158. PMID 23465250. Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial. Circ Cardiovasc Qual Outcomes. 2015;8(2):195-203. PMID 25737484.

References

↑ Gulati M, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Nov 30;144(22):e368-e454. PMID 34709879
↑ Kontos MC, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Nov 15;80(20):1925-1960. PMID 36241466
↑ Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454
↑ Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377
↑ Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077
↑ ^6.0 ^6.1 ^6.2 ^6.3 ^6.4 ^6.5 Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.
↑ Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.

Authors:

[1] Gulati M, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Nov 30;144(22):e368-e454. PMID 34709879

[2] Kontos MC, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Nov 15;80(20):1925-1960. PMID 36241466

[3] Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454

[4] Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377

[5] Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077

[“Mehta-6] 6.0 ^6.1 ^6.2 ^6.3 ^6.4 ^6.5 Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.

[7] Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.

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