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]
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.
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] |
| ||
NSTEMI/UA [8] |
| ||
Aortic dissection [9][10][11] |
|
| |
Cardiac tamponade [12] |
| ||
Pericarditis [13][14] |
|
| |
Heart failure exacerbation [15][16][17][18] |
| ||
Takotsubo cardiomyopathy [19][20] |
|
| |
Thoracic aortic aneurysm |
|
|
Pulmonary causes
Causes | Characteristic clinical features | Diagnostic findings | Acute management |
---|---|---|---|
Pulmonary embolism [21] |
|
| |
Tension pneumothorax [22][23] |
|
| |
Pneumonia [24] |
| ||
Spontaneous pneumothorax [22][25][26] |
| ||
Asthma exacerbation [27] |
|
| |
COPD exacerbation [28][29] |
|
| |
Pleural effusion [30][31] |
|
|
Gastrointestinal causes
Causes | Characteristic clinical features | Diagnostic findings | Acute management |
---|---|---|---|
Esophageal perforation [32][33] |
|
| |
GERD and erosive esophagitis [35][36] |
|
|
|
Gastritis [37] |
|
| |
Peptic ulcer disease [38][39][40] |
| ||
Acute pancreatitis [41][42][43] |
|
| |
Esophageal hypermotility disorders [44][45][46][47] |
|
| |
Mallory-Weiss syndrome [48][49] |
|
|
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
-
Pain management
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
-
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
See also ”Differential diagnosis of increased troponin” and “Differential diagnosis of ST elevations on ECG.”
- Acute coronary syndrome
- Cardiac tamponade
- Pericarditis
- Myocarditis
- Endocarditis
- Takotsubo cardiomyopathy
- Aortic dissection
- Valvular disease (e.g., aortic stenosis, mitral regurgitation, aortic regurgitation)
- Stable angina
- Vasospastic angina
- Hypertensive crisis
- Heart failure exacerbation
- Postcardiac injury syndrome
- Postmyocardial infarction syndrome
- Postpericardiotomy syndrome
Pulmonary
- Pulmonary embolism
- Tension pneumothorax
- Pneumothorax
- Pneumonia
- Bronchitis
- Asthma exacerbation
- COPD exacerbation
- Hemothorax
- Pulmonary edema
- Pleural effusion
-
Pleuritis
- Fibrinous pleuritis
- Rheumatoid pleuritis
- Lupus pleuritis
- Pulmonary sarcoidosis
- Lung contusion
- Pulmonary infarct
- Lung abscess
- Lung cancer
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
- 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.