• Clinical science
  • Physician

Chest pain (Thoracic pain)

Summary

Nontraumatic chest pain is one of the most common causes of emergency department visits and is common in both inpatients and outpatients. The differential diagnosis is broad and includes cardiac (e.g., acute coronary syndrome, pericarditis), gastrointestinal (e.g., GERD, gastritis, PUD), musculoskeletal (e.g., costochondritis), and psychiatric (e.g., generalized anxiety disorder, panic attack) etiologies. Any life-threatening causes of chest pain, such as acute coronary syndrome and pulmonary embolism, should be immediately evaluated and assessed. Once life-threatening causes have been ruled out (either by patient history, examination, or rapid diagnostics), a more thorough history and examination should be performed to narrow the differential diagnosis and guide further diagnostic workup and therapy. Traumatic causes of chest pain are not addressed here.

Approach

Approach to management [1]

  1. ABCDE survey
  2. Obtain 12-lead ECG: If ECG shows STEMI, see “Treatment” in acute coronary syndrome.
  3. Establish IV access.
  4. Continuous telemetry and pulse oximetry
  5. Initiate supplemental O2 if there is evidence of hypoxemia.
  6. Perform a focused history and physical examination.
  7. Perform targeted diagnostics (see “Diagnostics” below) and further tests as required.
  8. Treat the underlying cause.

Red flags for chest pain

Immediately life-threatening causes

Diagnostics

The diagnostic workup should be guided by the pretest probability of the diagnoses under consideration. The following list includes some commonly used diagnostic tools that can be helpful in diagnosing or ruling out possible etiologies in patients with undifferentiated chest pain.

Laboratory studies

Imaging

  • 12-lead ECG
  • X-ray of the chest
  • FAST bedside ultrasound
  • X-ray of the abdomen (upright)
  • X-ray of the ribs
  • CT chest with contrast
  • CT pulmonary angiogram
  • CT abdomen and pelvis with IV contrast
  • Right upper quadrant ultrasound
  • TTE and/or TEE
  • Lung ultrasound
  • V/Q scan
  • Duplex of the extremity

Cardiovascular causes

Characteristic clinical features Diagnostic findings Acute management
STEMI [4]
  • ECG: ST-segment elevation/depression, T-wave inversions, Q waves
  • Troponin
  • TTE: hypokinesis, regional wall motion abnormalities
NSTEMI/UA [5]
  • ECG: nonspecific changes, including T-wave inversions, ST-segment depressions
  • Increased or normal troponin
  • TTE: Regional wall motion abnormalities may be present.
Aortic dissection [6][7][8]
Cardiac tamponade [9]
  • ECG: low voltage, electrical alternans
  • CXR: enlarged cardiac silhouette
  • TTE: circumferential fluid layer, collapsible chambers , high EF, dilated IVC
    • Inspiration: Both ventricular and atrial septa move sharply to the left.
    • Expiration: Both ventricular and atrial septa move sharply to the right.
Pericarditis [10][11]
Heart failure exacerbation [12][13][14][15]

Gastrointestinal causes

Noncardiac chest pain is most commonly due to gastrointestinal and musculoskeletal disorders. [16]

Characteristic clinical features Diagnostic findings Acute management
Esophageal perforation [17][18]

GERD and erosive esophagitis [20][21]

  • Postprandial substernal chest pain, pressure, burning, reflux symptoms
  • Aggravated by lying in the supine position and certain foods (e.g., coffee, spices)
  • Epigastric tenderness
Peptic ulcer disease [22][23][24]
Acute pancreatitis [25][26][27]
  • Severe epigastric pain that radiates to the back
  • Nausea, vomiting
  • Epigastric tenderness, guarding, rigidity
  • Upper abdominal pain
  • Hypoactive bowel sounds
  • History of gallstones or alcohol use
Mallory-Weiss syndrome [28][29]

Pulmonary causes

Characteristic clinical features Diagnostic findings Acute management
Pulmonary embolism [30]
Tension pneumothorax [31][32]
Pneumonia [33]
Spontaneous pneumothorax [34][31][35]
  • Sudden, sharp unilateral chest pain
  • Acute dyspnea
  • Hypoxemia
  • Hyperresonance, decreased breath sounds on affected side
  • Crepitus
  • History of lung disease or trauma
Asthma exacerbation [36]
  • See the acute management checklist for asthma exacerbation.
Pleural effusion [37][38]

Other causes

Costochondritis [39]

  • Clinical features
    • Sharp, well-localized pain that is reproducible on palpation of costal cartilage
    • History of recent exercise/exertion/chest wall trauma
  • Diagnostics:
    • Clinical diagnosis [39]
    • CXR: normal
  • Treatment:

Acute herpes zoster [40][41]

Panic disorder [42]

Functional chest pain [20][44]

  • Clinical features:
  • Diagnostics:
    • Diagnosis of exclusion
    • Rome IV criteria for functional chest pain
  • Treatment:

Differential diagnoses

See also differential diagnosis of increased troponin and differential diagnosis of ST-elevations on ECG.

The differential diagnoses listed here are not exhaustive.

  • 1. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical; 2018.
  • 2. Ranasinghe AM, Strong D, Boland B, Bonser RS. Acute aortic dissection. BMJ. 2011; 343(jul29 2): pp. d4487–d4487. doi: 10.1136/bmj.d4487.
  • 3. Sherwood MW, Kristin Newby L. High‐Sensitivity Troponin Assays: Evidence, Indications, and Reasonable Use. Journal of the American Heart Association. 2014; 3(1). doi: 10.1161/jaha.113.000403.
  • 4. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012; 127(4): pp. 529–555. doi: 10.1161/cir.0b013e3182742c84.
  • 5. E. A. Amsterdam, N. K. Wenger, R. G. Brindis, D. E. Casey Jr., T. G. Ganiats, D. R. Holmes Jr., A. S. Jaffe, H. Jneid, R. F. Kelly, M. C. Kontos, G. N. Levine, P. R. Liebson, D. Mukherjee, E. D. Peterson, M. S. Sabatine, R. W. Smalling, S. J. Zieman. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. Journal of the American College of Cardiology. 2014. doi: 10.1016/j.jacc.2014.09.017.
  • 6. Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation. 2005; 112(24): pp. 3802–13. doi: 10.1161/CIRCULATIONAHA.105.534198.
  • 7. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Circulation. 2010; 121(13): pp. e266–369. doi: 10.1161/CIR.0b013e3181d4739e.
  • 8. Marik PE, Rivera R. Hypertensive emergencies. Curr Opin Crit Care. 2011; 17(6): pp. 569–580. doi: 10.1097/mcc.0b013e32834cd31d.
  • 9. Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003; 349(7): pp. 684–690. doi: 10.1056/nejmra022643.
  • 10. Snyder MJ, Bepko J, White M. Acute pericarditis: diagnosis and management. Am Fam Physician. 2014; 89(7): pp. 553–60. pmid: 24695601.
  • 11. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015; 36(42): pp. 2921–2964. doi: 10.1093/eurheartj/ehv318.
  • 12. Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med. 2018; 55(5): pp. 635–646. doi: 10.1016/j.jemermed.2018.08.002.
  • 13. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017; 136(6). doi: 10.1161/cir.0000000000000509.
  • 14. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary. J Am Coll Cardiol. 2013; 62(16): pp. 1495–1539. doi: 10.1016/j.jacc.2013.05.020.
  • 15. Van Diepen S, Katz JN, Albert NM, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2017; 136(16). doi: 10.1161/cir.0000000000000525.
  • 16. Cayley WE Jr. Diagnosing the cause of chest pain. Am Fam Physician. 2005; 72(10): pp. 2012–21. pmid: 16342831.
  • 17. Mavroudis CD, Kucharczuk JC. Acute Management of Esophageal Perforation. Current Surgery Reports. 2013; 2(1). doi: 10.1007/s40137-013-0034-x.
  • 18. Kaman L. Management of Esophageal Perforation in Adults. Gastroenterology Research. 2011. doi: 10.4021/gr263w.
  • 19. Søreide J, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2011; 19(1): p. 66. doi: 10.1186/1757-7241-19-66.
  • 20. Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology. 2008; 135(4): pp. 1383–1391.e5. doi: 10.1053/j.gastro.2008.08.045.
  • 21. Gyawali CP, Fass R. Management of Gastroesophageal Reflux Disease. Gastroenterology. 2018; 154(2): pp. 302–318. doi: 10.1053/j.gastro.2017.07.049.
  • 22. Kavitt RT, Lipowska AM, Anyane-Yeboa A, Gralnek IM. Diagnosis and Treatment of Peptic Ulcer Disease. Am J Med. 2019; 132(4): pp. 447–456. doi: 10.1016/j.amjmed.2018.12.009.
  • 23. Satoh K, Yoshino J, Akamatsu T, et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol. 2016; 51(3): pp. 177–194. doi: 10.1007/s00535-016-1166-4.
  • 24. Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician. 2015; 91(4): pp. 236–242. pmid: 25955624.
  • 25. Crockett et al. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018; 154(4): pp. 1096–1101. doi: 10.1053/j.gastro.2018.01.032.
  • 26. D Jeffrey. Acute Pancreatitis. AAFP. 2014. url: https://www.aafp.org/afp/2014/1101/p632.html.
  • 27. Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology. 2018; 154(4): pp. 1103–1139. doi: 10.1053/j.gastro.2018.01.031.
  • 28. Kim H-S. Endoscopic Management of Mallory-Weiss Tearing. Clin Endosc. 2015; 48(2): p. 102. doi: 10.5946/ce.2015.48.2.102.
  • 29. Rawla, Prashanth; Devasahayam, Joe. Mallory Weiss Syndrome. https://www.ncbi.nlm.nih.gov/books/NBK538190/. Updated November 24, 2019. Accessed January 6, 2020.
  • 30. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016; 149(2): pp. 315–352. doi: 10.1016/j.chest.2015.11.026.
  • 31. Leech C, Porter K, Steyn R, et al. The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh. Trauma. 2016; 19(1): pp. 54–62. doi: 10.1177/1460408616664553.
  • 32. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emergency Medicine Journal. 2004; 22(1): pp. 8–16. doi: 10.1136/emj.2003.010421.
  • 33. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007; 44(Supplement_2): pp. S27–S72. doi: 10.1086/511159.
  • 34. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001; 119(2): pp. 590–602. doi: 10.1378/chest.119.2.590.
  • 35. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010; 65(Suppl 2): pp. ii18–ii31. doi: 10.1136/thx.2010.136986.
  • 36. Camargo CA, Rachelefsky G, Schatz M. Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations. Proc Am Thorac Soc. 2009; 6(4): pp. 357–366. doi: 10.1513/pats.p09st2.
  • 37. Hooper et al. Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010. Thorax. ; 65: pp. ii4–ii17. doi: 10.1136/thx.2010.136978.
  • 38. Karkhanis V, Joshi J. Pleural effusion: diagnosis, treatment, and management. Open Access Emergency Medicine. 2012: p. 31. doi: 10.2147/oaem.s29942.
  • 39. Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009; 80(6): pp. 617–20. pmid: 19817327.
  • 40. Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the Management of Herpes Zoster. Clinical Infectious Diseases. 2007; 44(Supplement_1): pp. S1–S26. doi: 10.1086/510206.
  • 41. Saguil A, Kane S, Mercado M, Lauters R. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. Am Fam Physician. 2017; 96(10): pp. 656–663. pmid: 29431387.
  • 42. Fleet RP, Dupuis G, Marchand A, Burelle D, Arsenault A, Beitman BD. Panic disorder in emergency department chest pain patients: Prevalence, comorbidity, suicidal ideation, and physician recognition. Am J Med. 1996; 101(4): pp. 371–380. doi: 10.1016/s0002-9343(96)00224-0.
  • 43. Greenslade JH, Hawkins T, Parsonage W, Cullen L. Panic Disorder in Patients Presenting to the Emergency Department With Chest Pain: Prevalence and Presenting Symptoms. Heart, Lung and Circulation. 2017; 26(12): pp. 1310–1316. doi: 10.1016/j.hlc.2017.01.001.
  • 44. Remes-Troche JM. How to Diagnose and Treat Functional Chest Pain. Curr Treat Options Gastroenterol. 2016; 14(4): pp. 429–443. doi: 10.1007/s11938-016-0106-y.
  • Loffroy R, Favelier S, Pottecher P, et al. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging. 2015; 96(7-8): pp. 731–744. doi: 10.1016/j.diii.2015.05.002.
  • Roman S, Kahrilas PJ. Management of Spastic Disorders of the Esophagus. Gastroenterol Clin North Am. 2013; 42(1): pp. 27–43. doi: 10.1016/j.gtc.2012.11.002.
  • Brenner B, Corbridge T, Kazzi A. Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory Failure. Proc Am Thorac Soc. 2009; 6(4): pp. 371–379. doi: 10.1513/pats.p09st4.
  • Salas M, Ward A, Caro J. Are proton pump inhibitors the first choice for acute treatment of gastric ulcers? A meta analysis of randomized clinical trials. BMC Gastroenterol. 2002; 2(1). doi: 10.1186/1471-230x-2-17.
  • Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo Cardiomyopathy. Circulation. 2008; 118(25): pp. 2754–2762. doi: 10.1161/circulationaha.108.767012.
  • Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Advances. 2018; 2(22): pp. 3198–3225. doi: 10.1182/bloodadvances.2018022954.
  • January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014; 64(21): pp. e1–e76. doi: 10.1016/j.jacc.2014.03.022.
  • Khan AN, Cho KJ. Aortic Dissection Imaging. In: Aortic Dissection Imaging. New York, NY: WebMD. http://emedicine.medscape.com/article/416776-overview#showall. Updated May 13, 2016. Accessed December 4, 2016.
  • Ghadri J-R, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 2018; 39(22): pp. 2032–2046. doi: 10.1093/eurheartj/ehy076.
  • Lynch KL. Achalasia. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/achalasia. Updated July 1, 2019. Accessed November 15, 2019.
  • Stoller JK. Acute Exacerbations of Chronic Obstructive Pulmonary Disease. N Engl J Med. 2002; 346(13): pp. 988–994. doi: 10.1056/nejmcp012477.
  • Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017; 112: pp. 212–238. doi: 10.1038/ajg.2016.563.
  • O'Connel TX, Movalia M. Brochert's Crush Step 2: The Ultimate USMLE Step 2 Review. Saunders; 2012.
  • Stark P. Imaging of pneumothorax. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/imaging-of-pneumothorax. Last updated March 1, 2017. Accessed April 7, 2017.
  • Basurto Ona et al. Opioids for acute pancreatitis pain. Cochrane Database of Systematic Reviews. 2013. doi: 10.1002/14651858.cd009179.pub2.
  • Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017; 18(1): pp. 1–76. doi: 10.1089/sur.2016.261.
  • Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2013; 62(16): pp. e147–e239. doi: 10.1016/j.jacc.2013.05.019.
  • Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2020 Report. http://www.goldcopd.org. Accessed June 27, 2019.
  • Khalaf M, Chowdhary S, Elias PS, Castell D. Distal Esophageal Spasm: A Review. Am J Med. 2018; 131(9): pp. 1034–1040. doi: 10.1016/j.amjmed.2018.02.031.
  • Ghadri J-R, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management. Eur Heart J. 2018; 39(22): pp. 2047–2062. doi: 10.1093/eurheartj/ehy077.
  • Felker GM, Lee KL, Bull DA, et al. Diuretic Strategies in Patients with Acute Decompensated Heart Failure. N Engl J Med. 2011; 364(9): pp. 797–805. doi: 10.1056/nejmoa1005419.
  • Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. Circulation. 2016; 133(14). doi: 10.1161/cir.0000000000000311.
  • Lynch KL. Diffuse Esophageal Spasm. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/diffuse-esophageal-spasm. Updated July 1, 2019. Accessed November 15, 2019.
  • Lynch KL. Esophageal Motility Disorders. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/esophageal-motility-disorders#:~:targetText=Symptoms%20of%20esophageal%20motility%20disorders,pain%2C%20and%2For%20heartburn.. Updated July 1, 2019. Accessed November 15, 2019.
  • Achem SR, Gerson LB. Distal Esophageal Spasm: An Update. Curr Gastroenterol Rep. 2013; 15(9). doi: 10.1007/s11894-013-0325-5.
  • Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018; 67(3): pp. 103–108. doi: 10.15585/mmwr.mm6703a5.
last updated 03/16/2020
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