Chest pain

Last updated: August 17, 2023

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.”

Initial management

The following recommendations are consistent with the 2021 American Heart Association (AHA) chest pain guidelines. ^[1]

Life-threatening causes of acute chest pain

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

All patients
- ABCDE survey
- Focused clinical evaluation
- 12-lead ECG within 10 minutes of patient arrival
- IV access
- Routine diagnostic studies (e.g., troponin, CXR)
- Identify and treat the underlying cause.
Red flags for chest pain present: i.e., high risk of critical causes of chest pain
- Perform POCUS (e.g., eFAST). ^[1]^[4]
- Begin time-sensitive management (e.g., activate cath lab for STEMI).
- Obtain definitive imaging (e.g., CTA chest for TAA).
- Consider urgent specialty consult and critical care unit admission.
Red flags for chest pain absent: i.e., low risk of critical causes of chest pain
- Consider additional studies (see “Diagnostics for chest pain”).
- Use risk stratification tools, e.g.:
  - HEART score for risk stratification for ACS
  - Wells score for PE (see also “PE diagnostics”)
- Consider inpatient admission if the diagnosis is uncertain or clinical suspicion of a critical cause 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 they 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 that is 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

Applicable to most patients with undifferentiated chest pain

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

Cardiovascular causes of chest pain
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 Aortic dissection (Stanford type A) Electrical alternans

Pulmonary causes

Pulmonary causes of chest pain
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

Gastrointestinal causes of chest pain
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]

Definition: an inflammation of rib cage cartilage (esp. of the costochondral and costosternal junction)
Etiology: often occurs as a result of excessive exercise or minor chest wall trauma
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
  - Physical therapy (i.e., stretching exercises)
  - 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.)

Functional chest pain ^[35]^[54]

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 ^[54]
- 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)

Etiology

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

Hiatal hernia

Renal

Renal infarct
Renal capsular hematoma

Dermatological

Hematologic/Oncologic

Rheumatologic

Psychiatric

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Chest pain

Summary

Initial 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]

Functional chest pain [35][54]

Etiology

Cardiac

Pulmonary

Musculoskeletal

Gastrointestinal

Renal

Dermatological

Hematologic/Oncologic

Rheumatologic

Psychiatric

Related One-Minute Telegram

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]

Functional chest pain ^[35]^[54]