Chest pain

Last updated: May 12, 2022

Summary

Nontraumatic chest pain is one of the most common reasons that patients visit the emergency department; it is also frequently encountered in both the inpatient and outpatient settings. The differential diagnosis is broad and includes cardiac (e.g., acute coronary syndrome, pericarditis), gastrointestinal (e.g., gastritis, peptic ulcer disease), pulmonary (e.g., pulmonary embolism, tension pneumothorax), musculoskeletal (e.g., costochondritis, rib contusion), and psychiatric (e.g., generalized anxiety disorder, panic disorder) etiologies. Patients with red flag features suggestive of life-threatening causes (e.g., acute coronary syndrome, pulmonary embolism) and those who are hemodynamically unstable require immediate assessment. 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.

For traumatic causes of chest pain, see “Blunt chest trauma” and “Penetrating chest trauma.”

Management

The following recommendations are consistent with the 2021 American Heart Association (AHA) guideline for evaluating and diagnosing chest pain. ^[1]

Life-threatening causes of acute chest pain

Approach ^[1]^[2]^[3]

Assume that all chest pain is life-threatening until proven otherwise and perform the following steps concurrently, not sequentially.

All patients
- Perform an ABCDE assessment and stabilize accordingly, e.g., start oxygen therapy for hypoxemia.
- Establish IV access and initiate continuous telemetry with pulse oximetry.
- Perform a focused clinical evaluation.
  - History should include characteristics and duration of chest pain, associated symptoms, and cardiovascular and prothrombotic risk factors.
  - Physical examination should include cardiac examination, pulmonary examination, and abdominal examination.
  - Identify red flags in chest pain and estimate the likelihood of immediately life-threatening causes of chest pain.
- Obtain 12-lead ECG within 10 minutes of patient arrival.
- Order CXR and initial laboratory studies including troponin.
- Identify and treat the underlying cause: E.g., see “Cardiovascular causes of chest pain,” “Pulmonary causes of chest pain,” and “Gastrointestinal causes of chest pain.”
Red flags for chest pain present: i.e., high risk of immediately life-threatening causes of chest pain
- Perform a point-of-care ultrasound (e.g. eFAST) ^[1]^[4]
- Obtain definitive imaging (e.g., CTA chest for TAA) once stabilized.
- Begin time-sensitive management steps: e.g., activate cardiac cath lab for urgent PCI in case of STEMI.
- Admit for observation, monitoring, and definite management.
- Consider urgent specialty consultation and critical care unit admission.
Red flags for chest pain absent: i.e., low risk of immediately life-threatening causes of chest pain
- Consider additional laboratory and imaging studies (see “Diagnostics” for a comprehensive list).
- Use risk stratification tools if applicable, for example:
  - HEART score: predicts the risk for major adverse cardiac events (See also “Risk stratification for ACS.”)
  - Wells score for PE: assesses the probability of pulmonary embolism (See also “PE diagnostics.”)
- Treat the underlying condition once the diagnosis is established.
- Consider inpatient admission for observation and serial investigations if the diagnosis is uncertain or clinical suspicion for a concerning etiology persists.

Begin management of hemodynamic instability (e.g., shock, hypertensive emergency), signs of respiratory distress, and/or respiratory failure (e.g., hypoxia, hypercapnia) as soon as these are identified.

HEART score Wells Criteria for pulmonary embolism

Red flags in chest pain ^[1]^[5]

Symptoms
- Sudden onset
- Exertional chest pain
- Substernal or left-sided pain
- Radiation to the left arm, jaw, and/or back
- Quality of chest pain: crushing, pressure , tearing, and/or ripping
- Associated symptoms: shortness of breath, diaphoresis, nausea, and/or vomiting
Signs
- Vital sign abnormalities (e.g., hypoxia, hypotension)
- Pulsus paradoxus
- Difference of > 20 mm Hg in systolic blood pressure between arms ^[5]
- New murmur
- Chest wall crepitus
- Distant heart sounds

Chest tightness with radiation to the left arm, jaw, and/or back, associated with dyspnea should be considered cardiac chest pain until proven otherwise. ^[1]

Immediately life-threatening causes of chest pain ^[1]

Diagnostics

The diagnostic evaluation of undifferentiated chest pain aims to first rule out immediately life-threatening causes of chest pain and then determine the etiology, guided by the pretest probability of the diagnoses under consideration.

Perform a 12-lead ECG for all patients with new or evolving chest pain as soon as possible, e.g., for timely identification of acute coronary syndrome.

Laboratory studies

Routine investigations

Obtain the following initial studies for all patients:

Additional investigations

Consider ordering the following studies concurrently with routine studies based on clinical assessment and pretest probability:

BNP or NT-proBNP
D-dimer
Lactate
Preoperative studies: PT, PTT, type and screen
Abdominal studies: LFTs , lipase, amylase
Acute phase reactants: ESR, CRP , procalcitonin
Cultures: blood cultures, sputum cultures
Acute viral hepatitis panel
Respiratory viral panel
Urine toxicology screen

Imaging

Imaging is often required to confirm the diagnosis and rule out differential diagnoses. The choice of initial modality is usually based on the patient's clinical status, the pretest probability of the underlying etiology, and resource availability.

Bedside investigations

The following studies can be performed on unstable patients in most emergency settings:

Portable CXR (anteroposterior view)
POCUS (e.g., eFAST, biliary POCUS, POCUS for AAA) ^[1]^[4]
Lung ultrasound
Portable abdominal x-ray (upright)
Echocardiography (e.g., TTE, TEE)

Additional investigations

The following studies typically require the patient to be stable enough for transfer to a dedicated imaging suite:

CXR (posteroanterior and lateral; rib series if there is concern for rib fracture)
Abdominal series x-ray
CT chest (with IV contrast)
CTA chest (pulmonary embolism protocol)
CTA chest, abdomen, and pelvis (to evaluate the aorta)
Ultrasound right upper quadrant
Lower extremity venous ultrasound
V/Q scan

Cardiovascular causes

Causes	Characteristic clinical features	Diagnostic findings	Acute management
STEMI ^[7]	Heavy, dull, pressure/squeezing sensation Substernal pain with radiation to left shoulder Nausea, vomiting Diaphoresis, anxiety Dizziness, lightheadedness, syncope Pain may improve with nitroglycerin.	Labs: ↑ Troponin ECG: ST-segment elevation/depression, T-wave inversions, Q waves TTE: hypokinesis, regional wall motion abnormalities	See “Acute management checklist for STEMI.”
NSTEMI/UA ^[8]		Labs: Increased or normal troponin ECG: nonspecific changes, including T-wave inversions, ST-depressions TTE: Regional wall motion abnormalities may be present.	See “Acute management checklist for NSTEMI/UA.”
Aortic dissection ^[9]^[10]^[11]	Sudden onset of severe, sharp tearing chest or abdominal pain that radiates to the back Hypertension or hypotension Asymmetrical blood pressure, pulse deficit New diastolic murmur Symptoms of myocardial ischemia Syncope, neurological symptoms	Labs: Elevated D-dimer ECG: nonspecific ST-segment changes CXR: widening of the aorta CTA chest, abdomen, and pelvis: intimal flap with false lumen TEE: proximal aortic dissection, tamponade, aortic regurgitation	See “Acute management checklist for aortic dissection.”
Cardiac tamponade ^[12]	Tachypnea, dyspnea Tachycardia Pulsus paradoxus Cardiogenic shock Beck triad: hypotension, JVD, muffled heart sounds	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.	See “Acute management checklist for cardiac tamponade.”
Pericarditis ^[13]^[14]	Sharp, pleuritic, retrosternal chest pain Exacerbated by lying down; improved by leaning forward Not relieved with nitrates High-pitched pericardial friction rub	Labs: ↑ ESR, ↑ CRP, leukocytosis, ↑ troponin ^[13] ECG: diffuse ST-elevations without reciprocal ST-depressions, PR-segment depression, or T-wave inversions CXR: normal TTE: pericardial effusion may be present.	See “Acute management checklist for acute pericarditis.”
Heart failure exacerbation ^[15]^[16]^[17]^[18]	Chest pressure Cough, dyspnea Hypoxemia Crackles, JVD, peripheral edema	Clinical diagnosis Labs: ↑ BNP, ↑ troponin , abnormal BMP CXR: diffuse opacities, Kerley B lines TTE: global or focal wall abnormalities, systolic and/or diastolic dysfunction, decreased LVEF	See “Acute management checklist for heart failure exacerbation.”
Takotsubo cardiomyopathy ^[19]^[20]	History of a recent stressful event Retrosternal chest pain, dyspnea, heavy, dull, pressure/squeezing sensation Hypotension, cardiogenic shock Most common in older women	Labs: ↑ Troponin, ↑ BNP ECG: ST-elevations, T-wave inversions TTE: decreased LVEF, regional wall motion abnormalities , apical ballooning cMRI: myocardial edema, regional wall motion abnormalities Coronary angiography: no acute coronary stenosis or occlusion	See “Acute management checklist for Takotsubo cardiomyopathy.”
Thoracic aortic aneurysm	Feeling of pressure in the chest Thoracic back pain Features of mediastinal compression or obstruction (e.g., difficulty swallowing, hoarseness) If ruptured: severe chest pain, possible loss of consciousness	Chest x-ray: abnormal aortic contour, widened mediastinum, tracheal deviation CTA chest: dilation of the aorta, possible mural thrombus, dissection, perforation, or rupture	See “Acute management checklist for thoracic aortic aneurysm.”

Acute inferior ST-segment elevation myocardial infarction (STEMI) Acute anterior ST-elevation myocardial infarction (STEMI) Widened mediastinum Aortic dissection Electrical alternans

Pulmonary causes

Causes	Characteristic clinical features	Diagnostic findings	Acute management
Pulmonary embolism ^[21]	Pleuritic chest pain Acute onset dyspnea, hypoxemia Cough, hemoptysis Unilateral leg swelling or history of DVT Hypotension, shock (if massive PE)	Labs Elevated D-dimer ↑ Troponin, BNP ECG: normal sinus rhythm (most common), sinus tachycardia, signs of right ventricular strain CTA chest (pulmonary embolism protocol): pulmonary artery filling defect V/Q scan: perfusion-ventilation mismatch TTE: right ventricle hypokinesis with normal apical movement Clinical calculators Wells score PERC rule PESI	See “Acute management checklist for pulmonary embolism.”
Tension pneumothorax ^[22]^[23]	Severe, sharp chest pain Dyspnea, hypoxemia History of trauma Hyperresonance on percussion, decreased breath sounds, tracheal deviation Tachycardia, hypotension	Clinical diagnosis CXR: absent lung markings, tracheal deviation, pneumomediastinum	See “Acute management checklist for tension pneumothorax.”
Pneumonia ^[24]	Fever, chills Cough, dyspnea Hypoxemia Crackles, egophony	Labs: leukocytosis, ↑ ESR/CRP, ↑ procalcitonin Positive sputum culture CXR: consolidation, pleural effusion CT chest: hyperdense consolidation	See “Acute management checklist for pneumonia.”
Spontaneous pneumothorax ^[22]^[25]^[26]	Sudden, sharp unilateral chest pain Acute dyspnea Hypoxemia Hyperresonance on percussion, decreased breath sounds on the affected side Crepitus History of lung disease or trauma	Inspiratory CXR: increased lucency, displaced lung markings, subcutaneous emphysema POCUS: absent lung sliding on eFAST	See “Acute management checklist for spontaneous pneumothorax.”
Asthma exacerbation ^[27]	Dyspnea, cough Tachycardia Tachypnea, hypoxemia Diffuse wheezing Decreased or absent breath sounds Increased work of breathing	Peak expiratory flow: decreased from predicted or personal best ABG: ↓ pH, ↑ P_aCO₂, ↓ P_aO₂ (respiratory acidosis)	See “Acute management checklist for asthma exacerbation.”
COPD exacerbation ^[28]^[29]	Dyspnea, cough Purulent sputum Tachypnea, hypoxemia Diffuse wheezing, decreased breath sounds Increased work of breathing Signs of imminent respiratory arrest: confusion, absent breath sounds, bradycardia	ABG: ↓ pH, ↑ P_aCO₂, ↓ P_aO₂ (respiratory acidosis) Labs: ↑ CRP,↑ Procalcitonin (if underlying bacterial infection) CXR: hyperinflated lungs; signs of pneumonia, pneumothorax, and/or pleural effusion may be present	See “Acute management checklist for COPD exacerbation.”
Pleural effusion ^[30]^[31]	Unilateral, pleuritic chest pain Dyspnea Dry, nonproductive cough Dullness to percussion, decreased breath sounds, decreased tactile fremitus Pleural friction rub	CXR: homogeneous opacity with blunting of the costophrenic angle POCUS: hypoechoic space between the parietal and visceral pleura	See “Acute management checklist for pleural effusion.”

Management of pulmonary embolism Wells Criteria for pulmonary embolism Pulmonary embolism rule-out criteria (PERC) Pulmonary embolism severity index (PESI)

Gastrointestinal causes

Causes	Characteristic clinical features	Diagnostic findings	Acute management
Esophageal perforation ^[32]^[33]	Retrosternal chest pain, neck pain, epigastric pain with radiation to the back Dyspnea, tachypnea, tachycardia Dysphagia Signs of sepsis Mackler triad (chest pain, vomiting, subcutaneous emphysema) Mediastinal crepitus History of recent endoscopy or severe emesis (Boerhaave syndrome)	CXR, upright AXR: mediastinal air and/or subdiaphragmatic air, pleural effusion, pneumothorax Lateral neck x-ray: subcutaneous emphysema Contrast esophagography (gold standard): contrast leak ^[34] CT chest (with oral contrast) : extraluminal air, esophageal thickening	See “Acute management checklist for esophageal perforation.”
GERD and erosive esophagitis ^[35]^[36]	Postprandial substernal chest pain, pressure, burning, reflux symptoms Aggravated by lying in the supine position and certain foods (e.g., coffee, spices) Epigastric tenderness	Clinical diagnosis Definitive diagnosis requires EGD and/or 24-hour esophageal pH monitoring	See “Management of GERD.”
Gastritis ^[37]	Dyspepsia Postprandial fullness Epigastric tenderness	Clinical diagnosis Follow the test-and-treat strategy for Helicobacter pylori in most patients with upper GI symptoms. Consider EGD with biopsies in selected cases (e.g., patients aged > 60 years).	Antacids and acid reducers H. pylori eradication therapy See “Treatment of gastritis.”
Peptic ulcer disease ^[38]^[39]^[40]	Epigastric pain Duodenal ulcer: pain relieved with food, weight gain Gastric ulcer: pain exacerbated by food, weight loss Signs of GI bleed History of frequent NSAID use	Labs: ↓ Hb, ↓ Hct, ↓ RBC count, positive FOBT or melena (in patients with a bleeding ulcer) Urea breath test for H. pylori: positive in most cases of PUD EGD: mucosal erosions and/or ulcers	See “Acute management checklist for PUD.”
Acute pancreatitis ^[41]^[42]^[43]	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	Labs: ↑ Lipase, ↑ amylase Abdominal ultrasound: pancreatic edema, peripancreatic fluid, gallstones Abdominal CT with IV contrast : pancreatic edema, peripancreatic fat stranding, gallstones	See “Acute management checklist for acute pancreatitis.”
Esophageal hypermotility disorders ^[44]^[45]^[46]^[47]	Episodic retrosternal chest pain Intermittent dysphagia, globus sensation Reflux symptoms Symptoms aggravated by stress and/or hot and cold food and drink	Upper GI endoscopy: typically normal Barium swallow: normal or corkscrew esophagus appearance Esophageal manometry: premature and/or hypertensive esophageal contractions	See “Acute management checklist for esophageal hypermotility disorders.”
Mallory-Weiss syndrome ^[48]^[49]	Epigastric pain that radiates to the back Repeated episodes of severe vomiting Hematemesis Melena, dizziness, syncope	CBC: anemia EGD: longitudinal mucosal tears, typically at the gastroesophageal junction	See “Acute management checklist for Mallory-Weiss syndrome.”

Noncardiac chest pain is most commonly caused by gastrointestinal and musculoskeletal disorders. ^[50]

Other causes

Costochondritis ^[51]

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 ^[51]
- CXR: normal
Treatment
- Pain management
  - Acetaminophen
  - NSAIDs (e.g., naproxen, ibuprofen )
- Supportive care: reduction of activities that provoke symptoms, cough suppressants, heat or ice packs

Herpes zoster ^[52]^[53]

Clinical features
- Severe burning or throbbing pain
- Thoracic dermatomes are most commonly affected
- Maculopapular rash that develops into a vesicular rash in a dermatomal distribution
- Immunocompromised status
Diagnostics
- Clinical diagnosis
- PCR of vesicle fluid positive for varicella-zoster virus DNA ^[53]
Treatment
- Antivirals (See the acute management checklist for herpes zoster.)

Panic disorder ^[54]

Clinical features
- Chest tightness, palpitations, tachycardia
- Tachypnea
- Diaphoresis, dizziness
- Paresthesias
- Anxious appearance
- Recent stressful exposure
Diagnostics: Clinical diagnosis
Treatment
- Breathing exercises
- Consider benzodiazepines for an acute episode (e.g., lorazepam, diazepam).
- Assess for suicidal ideation. ^[54]^[55]
- Psychiatry consult and/or referral for cognitive behavioral therapy

Functional chest pain ^[35]^[56]

Clinical features
- Retrosternal chest pain or discomfort
- No associated esophageal symptoms (e.g., no heartburn, dysphagia)
Diagnostics
- Diagnosis of exclusion
- Rome IV criteria for functional chest pain
Treatment
- Reassure the patient.
- Referral to psychologist ^[56]
- Consider initiating medical therapy with one of the following:
  - TCA (e.g., amitriptyline)
  - SARI (e.g., trazodone)
  - SSRI (e.g., sertraline)
  - SNRI (e.g., venlafaxine)

Differential diagnoses

Cardiac

Pulmonary

Musculoskeletal

Costochondritis
Chest trauma
Chest wall pain
Rib fracture
Rib contusion
Osteoarthritis of the sternoclavicular or manubriosternal joint
Osteoarthritis of the shoulder joints
Slipping rib syndrome
Tietze syndrome
Overuse myalgia
Thoracic outlet syndrome

Gastrointestinal

Esophageal perforation
Boerhaave syndrome
Mallory-Weiss syndrome
Gastroesophageal reflux disease
Acute erosive gastritis
Acute erosive esophagitis
Eosinophilic esophagitis
Dyspepsia
Peptic ulcer disease
Esophageal motility disorder
- Achalasia
- Distal esophageal spasm
- Hypercontractile esophagus
Esophageal hypersensitivity
Sliding hiatal hernia
Biliary colic
Cholelithiasis
Choledocholithiasis
Cholecystitis
Acute pancreatitis
Acute hepatitis
Liver abscess
Fitz-Hugh-Curtis syndrome

Renal

Renal infarct
Renal capsular hematoma

Dermatological

Hematologic/Oncologic

Rheumatologic

Psychiatric

Functional chest pain
Generalized anxiety disorder
Panic disorder
Major depressive disorder
Somatic symptom disorder
Substance use disorders (e.g., cocaine, methamphetamines, alcohol)
Illness anxiety disorder

The differential diagnoses listed here are not exhaustive.

References

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 . | Open in Read by QxMD
Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary. J Am Coll Cardiol. 2021; 78 (22): p.2218-2261. doi: 10.1016/j.jacc.2021.07.052 . | Open in Read by QxMD
Kreuter M, Mathis G. Emergency ultrasound of the chest.. Respiration. 2014; 87 (2): p.89-97. doi: 10.1159/000357685 . | Open in Read by QxMD
Mavroudis CD, Kucharczuk JC. Acute Management of Esophageal Perforation. Current Surgery Reports. 2013; 2 (1). doi: 10.1007/s40137-013-0034-x . | Open in Read by QxMD
Kaman L. Management of Esophageal Perforation in Adults. Gastroenterology Research. 2011 . doi: 10.4021/gr263w . | Open in Read by QxMD
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 . | Open in Read by QxMD
Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology. 2008; 135 (4): p.1383-1391.e5. doi: 10.1053/j.gastro.2008.08.045 . | Open in Read by QxMD
Gyawali CP, Fass R. Management of Gastroesophageal Reflux Disease. Gastroenterology. 2018; 154 (2): p.302-318. doi: 10.1053/j.gastro.2017.07.049 . | Open in Read by QxMD
Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol. 2017; 112 (7): p.988-1013. doi: 10.1038/ajg.2017.154 . | Open in Read by QxMD
Kavitt RT, Lipowska AM, Anyane-Yeboa A, Gralnek IM. Diagnosis and Treatment of Peptic Ulcer Disease. Am J Med. 2019; 132 (4): p.447-456. doi: 10.1016/j.amjmed.2018.12.009 . | Open in Read by QxMD
Satoh K, Yoshino J, Akamatsu T, et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol. 2016; 51 (3): p.177-194. doi: 10.1007/s00535-016-1166-4 . | Open in Read by QxMD
Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician.. 2015; 91 (4): p.236-242.
Crockett et al. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018; 154 (4): p.1096-1101. doi: 10.1053/j.gastro.2018.01.032 . | Open in Read by QxMD
D Jeffrey. Acute Pancreatitis. AAFP. 2014 .
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): p.1103-1139. doi: 10.1053/j.gastro.2018.01.031 . | Open in Read by QxMD
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.
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.
Khalaf M, Chowdhary S, Elias PS, Castell D. Distal Esophageal Spasm: A Review. Am J Med. 2018; 131 (9): p.1034-1040. doi: 10.1016/j.amjmed.2018.02.031 . | Open in Read by QxMD
Roman S, Kahrilas PJ. Management of Spastic Disorders of the Esophagus. Gastroenterol Clin North Am. 2013; 42 (1): p.27-43. doi: 10.1016/j.gtc.2012.11.002 . | Open in Read by QxMD
Kim H-S. Endoscopic Management of Mallory-Weiss Tearing. Clin Endosc. 2015; 48 (2): p.102. doi: 10.5946/ce.2015.48.2.102 . | Open in Read by QxMD
Mallory Weiss Syndrome. https://www.ncbi.nlm.nih.gov/books/NBK538190/. Updated: November 24, 2019. Accessed: January 6, 2020.
Cayley WE Jr. Diagnosing the cause of chest pain.. Am Fam Physician. 2005; 72 (10): p.2012-21.
O’Gara PT, Kushner FG, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation. 2013; 127 (4). doi: 10.1161/cir.0b013e3182742cf6 . | Open in Read by QxMD
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 . | Open in Read by QxMD
Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes.. Circulation. 2005; 112 (24): p.3802-13. doi: 10.1161/CIRCULATIONAHA.105.534198 . | Open in Read by QxMD
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): p.e266-369. doi: 10.1161/CIR.0b013e3181d4739e . | Open in Read by QxMD
Marik PE, Rivera R. Hypertensive emergencies. Curr Opin Crit Care. 2011; 17 (6): p.569-580. doi: 10.1097/mcc.0b013e32834cd31d . | Open in Read by QxMD
Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003; 349 (7): p.684-690. doi: 10.1056/nejmra022643 . | Open in Read by QxMD
Snyder MJ, Bepko J, White M. Acute pericarditis: diagnosis and management.. Am Fam Physician. 2014; 89 (7): p.553-60.
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): p.2921-2964. doi: 10.1093/eurheartj/ehv318 . | Open in Read by QxMD
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): p.635-646. doi: 10.1016/j.jemermed.2018.08.002 . | Open in Read by QxMD
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 . | Open in Read by QxMD
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): p.1495-1539. doi: 10.1016/j.jacc.2013.05.020 . | Open in Read by QxMD
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 . | Open in Read by QxMD
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): p.2032-2046. doi: 10.1093/eurheartj/ehy076 . | Open in Read by QxMD
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): p.2047-2062. doi: 10.1093/eurheartj/ehy077 . | Open in Read by QxMD
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016; 149 (2): p.315-352. doi: 10.1016/j.chest.2015.11.026 . | Open in Read by QxMD
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): p.54-62. doi: 10.1177/1460408616664553 . | Open in Read by QxMD
Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emergency Medicine Journal. 2004; 22 (1): p.8-16. doi: 10.1136/emj.2003.010421 . | Open in Read by QxMD
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): p.S27-S72. doi: 10.1086/511159 . | Open in Read by QxMD
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): p.590-602. doi: 10.1378/chest.119.2.590 . | Open in Read by QxMD
MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010; 65 (Suppl 2): p.ii18-ii31. doi: 10.1136/thx.2010.136986 . | Open in Read by QxMD
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): p.357-366. doi: 10.1513/pats.p09st2 . | Open in Read by QxMD
Stoller JK. Acute Exacerbations of Chronic Obstructive Pulmonary Disease. N Engl J Med. 2002; 346 (13): p.988-994. doi: 10.1056/nejmcp012477 . | Open in Read by QxMD
Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). http://www.goldcopd.org. . Accessed: June 27, 2019.
Hooper et al.. Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010. Thorax. undefined; 65 : p.ii4-ii17. doi: 10.1136/thx.2010.136978 . | Open in Read by QxMD
Karkhanis V, Joshi J. Pleural effusion: diagnosis, treatment, and management. Open Access Emergency Medicine. 2012 : p.31. doi: 10.2147/oaem.s29942 . | Open in Read by QxMD
Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment.. Am Fam Physician. 2009; 80 (6): p.617-20.
Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the Management of Herpes Zoster. Clinical Infectious Diseases. 2007; 44 (Supplement_1): p.S1-S26. doi: 10.1086/510206 . | Open in Read by QxMD
Saguil A, Kane S, Mercado M, Lauters R. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management.. Am Fam Physician. 2017; 96 (10): p.656-663.
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): p.371-380. doi: 10.1016/s0002-9343(96)00224-0 . | Open in Read by QxMD
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): p.1310-1316. doi: 10.1016/j.hlc.2017.01.001 . | Open in Read by QxMD
Remes-Troche JM. How to Diagnose and Treat Functional Chest Pain. Curr Treat Options Gastroenterol. 2016; 14 (4): p.429-443. doi: 10.1007/s11938-016-0106-y . | Open in Read by QxMD
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
Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
Ranasinghe AM, Strong D, Boland B, Bonser RS. Acute aortic dissection. BMJ. 2011; 343 (jul29 2): p.d4487-d4487. doi: 10.1136/bmj.d4487 . | Open in Read by QxMD
Khan AN, Cho KJ. Aortic Dissection Imaging. Aortic Dissection Imaging. New York, NY: WebMD. http://emedicine.medscape.com/article/416776-overview#showall. Updated: May 13, 2016. Accessed: December 4, 2016.
Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017; 112 : p.212-238. doi: 10.1038/ajg.2016.563 . | Open in Read by QxMD
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 . | Open in Read by QxMD
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): p.1-76. doi: 10.1089/sur.2016.261 . | Open in Read by QxMD
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): p.e147-e239. doi: 10.1016/j.jacc.2013.05.019 . | Open in Read by QxMD
Felker GM, Lee KL, Bull DA, et al. Diuretic Strategies in Patients with Acute Decompensated Heart Failure. N Engl J Med. 2011; 364 (9): p.797-805. doi: 10.1056/nejmoa1005419 . | Open in Read by QxMD
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): p.e506–e574. doi: 10.1161/cir.0000000000000311 . | Open in Read by QxMD
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): p.e1-e76. doi: 10.1016/j.jacc.2014.03.022 . | Open in Read by QxMD
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): p.3198-3225. doi: 10.1182/bloodadvances.2018022954 . | Open in Read by QxMD
Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo Cardiomyopathy. Circulation. 2008; 118 (25): p.2754-2762. doi: 10.1161/circulationaha.108.767012 . | Open in Read by QxMD
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 . | Open in Read by QxMD
Brenner B, Corbridge T, Kazzi A. Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory Failure. Proc Am Thorac Soc. 2009; 6 (4): p.371-379. doi: 10.1513/pats.p09st4 . | Open in Read by QxMD
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): p.731-744. doi: 10.1016/j.diii.2015.05.002 . | Open in Read by QxMD
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): p.103-108. doi: 10.15585/mmwr.mm6703a5 . | Open in Read by QxMD

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Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer

Chest pain

Summary

Management

Approach [1][2][3]

Red flags in chest pain [1][5]

Immediately life-threatening causes of chest pain [1]

Diagnostics

Laboratory studies

Routine investigations

Additional investigations

Imaging

Bedside investigations

Additional investigations

Cardiovascular causes

Pulmonary causes

Gastrointestinal causes

Other causes

Costochondritis [51]

Herpes zoster [52][53]

Panic disorder [54]

Functional chest pain [35][56]

Differential diagnoses

Cardiac

Pulmonary

Musculoskeletal

Gastrointestinal

Renal

Dermatological

Hematologic/Oncologic

Rheumatologic

Psychiatric

References

3 free articles remaining

Approach ^[1]^[2]^[3]

Red flags in chest pain ^[1]^[5]

Immediately life-threatening causes of chest pain ^[1]

Costochondritis ^[51]

Herpes zoster ^[52]^[53]

Panic disorder ^[54]

Functional chest pain ^[35]^[56]