Chest Pain

on call  ›  complaints
reference sheet complaint/chest-pain

Chest Pain

ABCs
  • assess airway, breathing, circulation
  • full vitals + cardiac monitor
  • measure BP in both arms, especially if dissection is a possibility
  • O₂ only if SpO₂ < 90%, target ≥ 90%, no routine O₂ if ≥ 90%
  • secure IV access
escalate now if
  • hemodynamic instability
  • cardiac chest pain (exertional, substernal, radiating)
  • sudden severe pain (tearing or ripping)
  • respiratory compromise
  • autonomic symptoms (diaphoresis, N/V)
  • neurological signs or syncope
  • unequal pulses or BP difference > 20 mmHg
  • new murmur or distant heart sounds
  • signs of DVT
  • chest wall crepitus

differential: what could this be
critical, always rule out first
  • ACS (STEMI / NSTEMI / unstable angina) → exertional or cardiac-type pain, ECG or troponin changes
  • aortic dissection → sudden tearing or ripping pain, pulse or BP differential, new murmur
  • cardiac tamponade → Beck’s triad, muffled heart sounds, distended neck veins, hypotension
  • SCAD → often younger, female, peripartum or extreme exertion, few atherosclerotic risk factors
  • esophageal perforation / Boerhaave → severe pain after forceful vomiting or endoscopy, subcutaneous emphysema
  • PE → pleuritic pain, dyspnea, tachycardia, DVT signs, hypoxia
  • tension pneumothorax → sudden dyspnea, unilateral absent breath sounds, tracheal deviation, hypotension
emergent / important, not equally likely as the above
  • cholecystitis → RUQ pain radiating to the right shoulder or chest, fever, Murphy’s sign
  • cocaine-associated chest pain → recent use, younger patient, coronary vasospasm, avoid unopposed β-blockade
  • mediastinitis → recent esophageal instrumentation or cardiac surgery, fever, severe retrosternal pain
  • myocardial rupture / post-MI mechanical complication → days after MI, new murmur, sudden hemodynamic collapse
  • myocarditis → recent viral illness, younger patient, heart failure signs, troponin rise without obstructive disease
  • pancreatitis → epigastric pain radiating to the back, lipase elevated, alcohol or gallstone history
  • pericarditis → pleuritic, positional, relieved leaning forward, friction rub
  • pneumothorax (non-tension) → unilateral reduced breath sounds, hyperresonance, pleuritic pain
also consider, more common, less dangerous
  • MSK pain: localized, reproducible on palpation
  • pneumonia / HAP: fever, cough, focal signs

HPI & examination
  • pain characteristics
    • character: heaviness vs sharp
    • exertional vs pleuritic
    • radiation: arm, jaw, back
  • associated symptoms
    • diaphoresis, palpitations, N/V
    • dyspnea, orthopnea, PND
    • fever, cough
    • DVT symptoms
  • history & exam
    • PMH: IHD, lung disease, asthma, reflux
    • full cardiorespiratory exam
    • lower-limb exam (DVT signs)

send now / workup
all patients
  • ECG within 10 min of first medical contact when ACS is suspected, interpreted immediately
  • repeat ECG if symptoms change, or if the first is nondiagnostic and suspicion remains
  • CXR when clinically appropriate
moderate to high risk
  • high-sensitivity troponin now, repeat per the validated local pathway (commonly 0/1 h or 0/2 h); the interval depends on the assay, not one universal number
  • CBC, renal profile / electrolytes
  • coagulation studies when indicated (anticoagulant use, planned intervention, bleeding risk)
if PE is suspected
  • apply a validated pre-test probability tool first, do not send D-dimer indiscriminately or jump straight to CTPA
  • D-dimer when pre-test probability is low to moderate; CTPA when indicated (high probability, or a positive D-dimer)
  • the YEARS algorithm is a validated alternative that adjusts the D-dimer threshold by risk criteria
  • high or intermediate probability, imaging delayed
    • bleeding risk low → empiric therapeutic anticoagulation while awaiting imaging is reasonable
    • bleeding risk high → unfractionated heparin (short half-life, reversible), or hold for imaging per senior
calculator Wells’ Criteria for PE · MDCalc ↗︎ · PERC Rule · MDCalc ↗︎
if aortic dissection is suspected
  • CTA aorta, chest to pelvis: full extent and branch-vessel involvement; chest-only acceptable only for rapid triage, and must be extended if dissection is confirmed
  • correlate with bedside findings (pulse or BP differential, new murmur) and renal / hemodynamic status: malperfusion changes management urgency
if heart failure is suspected
  • BNP or NT-proBNP when diagnostic uncertainty exists
bedside echo / POCUS
  • pericardial effusion or tamponade physiology
  • RV strain
  • gross regional or global LV dysfunction
  • aortic root abnormality
  • POCUS does not exclude ACS, PE, or dissection on its own: a normal scan does not stop the workup
calculator HEART score · MDCalc ↗︎

treat
ACS: STEMI / NSTEMI / unstable angina
  • cardiology, early
  • aspirin 300 mg chewed for every suspected ACS with no contraindication
  • P2Y12 and anticoagulation are not one identical bundle for every patient: choice and timing depend on STEMI vs NSTE-ACS, whether an invasive strategy is planned, bleeding risk, contraindications, and the local cardiology pathway
    • ticagrelor or prasugrel preferred over clopidogrel when PCI is planned, for both STEMI and NSTE-ACS
    • upstream oral P2Y12 loading before angiography is only considered in NSTE-ACS when angiography is expected > 24 h away
  • parenteral anticoagulation: unfractionated heparin, enoxaparin 1 mg/kg SC q12h, or fondaparinux 2.5 mg SC OD, by strategy (invasive vs conservative), bleeding risk, and local protocol
    • fondaparinux given and primary PCI proceeds → add unfractionated heparin (catheter-thrombosis risk with fondaparinux alone)
  • STEMI → reperfusion now: primary PCI where available; fibrinolysis only if PCI not deliverable in time and no contraindication
  • GTN SL for ongoing ischemic pain (not if hypotensive / RV infarct / dissection)
  • IV opioid (morphine 2–5 mg IV) is not routine first-line
    • only for persistent severe ischemic pain despite maximal tolerated anti-ischemic therapy (nitrates, beta-blockade)
    • caution: slows GI motility, delays absorption / effect of oral P2Y12 agents
  • high-intensity statin for confirmed ACS: atorvastatin 80 mg PO or rosuvastatin 20–40 mg PO
  • POCUS is a useful adjunct (LV/RV, effusion, alternative causes of shock): do not let this delay reperfusion or definitive imaging
aortic dissection, unstable: shock, severe tearing pain
  • call for assistance now, cardiothoracic or vascular surgery by Stanford type
  • analgesia
  • rapid impulse control first: labetalol 20 mg IV over 1–2 min, then 40–80 mg IV every 10 min (or infusion 0.5–2 mg/min); esmolol is an alternative
    • targets: HR 60–80 bpm and SBP < 120 mmHg, or the lowest pressure maintaining end-organ perfusion
  • add a vasodilator only after adequate rate / impulse control, if BP remains above target
  • urgent CT angio
  • Stanford A → emergency surgery; Stanford B → urgent vascular / CT surgery for malperfusion or instability, medical management if uncomplicated
aortic dissection, stable: tearing pain, BP or pulse differential
  • CTA, chest to pelvis
  • same targets as unstable dissection: HR 60–80 bpm, SBP < 120 mmHg
  • β-blocker first, vasodilator only if BP remains above target
  • urgent vascular / CT surgery referral by Stanford type
cardiac tamponade
  • urgent echo to confirm and assess hemodynamic significance
  • immediate cardiology / critical care escalation
  • echo-guided pericardiocentesis if hemodynamically unstable; a stable incidental effusion is drained in a controlled setting (cath lab / OR) under specialist care, not at the bedside
PE
  • CTPA if stable
  • anticoagulation: enoxaparin 1 mg/kg SC q12h, or per local protocol / renal function
  • high-risk PE with hemodynamic instability → urgent reperfusion, time-critical
    • options: systemic thrombolysis (alteplase), catheter-directed therapy, surgical / mechanical thrombectomy
    • choose by contraindications, severity, and local resources or PERT-style input, not one fixed default
    • systemic thrombolysis is usually the fastest bedside option when not contraindicated
  • bedside echo for the unstable patient: confirms RV strain, supports the urgency, does not by itself decide the reperfusion method
pericarditis
  • NSAID (ibuprofen 600 mg TDS) + colchicine 0.5 mg OD–BD
tension pneumothorax: treat before imaging confirms it
  • immediate needle decompression, do not wait for a CXR
    • sites: 2nd intercostal space, midclavicular line (ETC) or 4th–5th intercostal space, anterior / mid-axillary line (ATLS)
    • guidance differs and comparative evidence is mixed: follow local emergency / trauma protocol for site choice
    • left side: favor the 2nd ICS midclavicular line, the heart sits closer to the lower lateral sites
  • followed by definitive chest tube: do not wait for a drain kit to decompress
pneumothorax, non-tension
  • urgent CXR
  • size and symptoms guide observation vs chest drain, per local protocol
esophageal perforation / Boerhaave syndrome
  • NPO
  • broad-spectrum antimicrobials covering GI flora and anaerobes → Empiric Antibiotics
  • urgent surgical / GI involvement
  • avoid oral contrast studies or endoscopy until surgery has reviewed
also: MSK pain, pneumonia / HAP
  • MSK, localized and reproducible: paracetamol 1 g PO/IV q6h (IV only if NPO or oral inadequate) ± NSAID if no contraindication
  • pneumonia (CAP or HAP, including the ≥48 h post-admission definition): antimicrobial choice by syndrome, severity, and risk factors → Empiric Antibiotics

escalation / disposition
  • urgent escalation: STEMI, unstable dissection, tamponade, high-risk PE (hemodynamic instability), tension pneumothorax, Boerhaave, suspected myocardial rupture → call the relevant specialty immediately
  • if hemodynamic instability or shock develops → Advanced: Shock, Advanced: Cardiogenic Shock for cardiac etiologies
  • monitored evaluation: intermediate-risk ACS (e.g. HEART 4–6) or an unresolved high-risk differential → telemetry admission for serial troponin and reassessment
  • observation: low-risk chest pain, nondiagnostic first workup → short-stay / chest-pain-unit pathway for the second troponin and repeat ECG before disposition

evidence
source type
2021 AHA/ACC chest pain guideline international guideline
2025 ACC/AHA ACS guideline international guideline
ESC 0/1h and 0/2h hs-troponin algorithms international guideline
2022 ACC/AHA aortic disease guideline international guideline
2026 AHA/ACC multi-society acute PE guideline international guideline
ATLS 10th ed. / ETC / 2025 decompression meta-analysis specialty-society guidance

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

related
hypertension·
hypotension·
troponin·
oxygen desaturation·
dyspnea·
palpitations·
coagulation profile
go deeper MOC+ Vol 2 · Cardiopulmonary covers this in the full reference. or the complete set.

free the on-call checklist covers the whole shift on one printable page.

studying for the IM exam? the IM Rapid Review covers chest pain in the same format. see the sample chapter.

reviewed Aug 2026updated Sep 2026file complaint/chest-pain