Chest Pain
at the bedside
- airway, breathing, circulation; full vitals, cardiac monitor, IV access
- ECG within 10 min → compare with the old one
- BP in both arms → difference > 20 mmHg points to dissection
- O₂ only if SpO₂ < 90% → oxygen desaturation
escalate now if
- hemodynamic instability or shock
- STEMI or new ischemic ECG change → ACS
- tearing pain, arm BP difference > 20 mmHg, or new murmur → aortic dissection
- respiratory distress or SpO₂ < 90% → PE, dyspnea
- syncope or new neurological signs
- muffled heart sounds with distended neck veins → cardiac tamponade
- unilateral absent breath sounds → tension pneumothorax; chest wall crepitus after vomiting → Boerhaave
differentials
critical, rule out first
- ACS (STEMI / NSTEMI / unstable angina) → exertional or pressure-like pain, ECG or troponin change
- aortic dissection → sudden tearing pain, pulse or BP differential, new murmur
- cardiac tamponade → hypotension, muffled heart sounds, distended neck veins
- SCAD → younger, often female or peripartum, few 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, absent breath sounds one side, tracheal deviation, hypotension
important, less likely
- pericarditis → pleuritic, positional, better leaning forward, friction rub
- myocarditis → recent viral illness, younger, heart failure signs, troponin rise
- post-MI mechanical complication → days after MI, new murmur, sudden collapse
- cocaine-associated → recent use, younger; no unopposed β-blockade
- pneumothorax (non-tension) → reduced breath sounds one side, hyperresonance
- mediastinitis → recent esophageal instrumentation or cardiac surgery, fever
- cholecystitis → RUQ pain to the right shoulder, fever, Murphy’s sign
- pancreatitis → epigastric pain to the back, lipase raised
common, less dangerous
- MSK pain → localized, reproduced by palpation or movement
- pneumonia → fever, cough, focal crackles
- reflux / esophageal spasm → burning, after meals or lying flat, relieved by antacid; a diagnosis of exclusion
focused check
- pain
- onset → sudden vs gradual, at rest vs on exertion
- character → pressure vs sharp vs tearing; pleuritic or positional
- radiation → arm, jaw, back
- symptoms
- diaphoresis, nausea, palpitations
- dyspnea, orthopnea, PND
- fever, cough, vomiting before the pain
- leg swelling, immobility, recent surgery
- history → IHD, lung disease, reflux, cocaine, anticoagulants, recent procedure
- exam → pulses both sides, murmur or rub, breath sounds both sides, chest wall tenderness, calves
send now
all patients
- repeat ECG → if the pain changes or the first is nondiagnostic
- hs-troponin now → repeat at 1–3 h per the local assay pathway → troponin
- CBC, renal profile, electrolytes; coagulation if anticoagulated or an intervention is likely
- CXR
if PE is suspected
- Wells or PERC first → low probability: D-dimer; high probability or positive D-dimer: CTPA
- CTPA delayed, high probability → start anticoagulation now if bleeding risk is low; unfractionated heparin if high
if dissection is suspected
- CTA aorta, chest to pelvis
if heart failure is in question
- NT-proBNP → dyspnea
bedside echo / POCUS
- pericardial effusion or tamponade, RV strain, LV function, aortic root
- a normal scan does not exclude ACS, PE or dissection; the workup continues
calculator HEART score · MDCalc ↗︎
treat
ACS: STEMI / NSTEMI / unstable angina
- STEMI → cardiology now for primary PCI; fibrinolysis only if PCI cannot be delivered in time and nothing contraindicates it
- aspirin 300 mg chewed, unless contraindicated
- P2Y12 → cardiology chooses the drug and the timing: ticagrelor 180 mg or prasugrel 60 mg when PCI is planned; clopidogrel 300–600 mg with fibrinolysis, high bleeding risk or an oral anticoagulant
- NSTE-ACS → no loading before angiography unless it is > 24 h away
- anticoagulation → unfractionated heparin when going to the lab; enoxaparin 1 mg/kg SC q12h or fondaparinux 2.5 mg SC OD when managed conservatively
- fondaparinux and PCI → add unfractionated heparin in the lab
- GTN SL for ongoing pain → not if hypotensive, RV infarct, severe aortic stenosis or a recent PDE5 inhibitor
- morphine 2–5 mg IV only if pain persists despite nitrates; it delays oral P2Y12 absorption
- atorvastatin 80 mg PO (or rosuvastatin 20–40 mg) once ACS is confirmed
- no STEMI → telemetry, serial troponin; HEART ≥ 4 or pain that keeps returning → cardiology
aortic dissection
- type A → cardiothoracic surgery and ICU now; type B → vascular surgery, surgery if malperfusion, rupture or refractory pain
- IV opioid analgesia
- β-blocker first → labetalol 10–20 mg IV over 2 min, repeat or double every 10 min (20–80 mg), max 300 mg; esmolol if asthma or unsure of tolerance → hypertension
- targets → HR < 60 and SBP 100–120 mmHg, or the lowest that keeps the patient perfused
- vasodilator only after the rate is controlled, if SBP stays above target
- no antiplatelet, no anticoagulant until dissection is excluded
cardiac tamponade
- echo now; cardiology and ICU now
- fluid bolus may buy time; avoid diuretics and vasodilators
- unstable → echo-guided pericardiocentesis; a stable effusion is drained in the cath lab, not at the bedside
PE
- anticoagulation → enoxaparin 1 mg/kg SC q12h; unfractionated heparin if renal impairment, instability or reperfusion is possible
- unstable (SBP < 90 mmHg) → ICU now; systemic thrombolysis, alteplase 100 mg IV over 2 h, unless contraindicated; catheter-directed or surgical thrombectomy when it is
pericarditis
- first line → ibuprofen 600 mg TDS or aspirin 750–1000 mg TDS for 1–2 weeks then taper, plus colchicine 0.5 mg BD (0.5 mg OD if < 70 kg) for 3 months; PPI cover
- use aspirin, not another NSAID → post-MI pericarditis, or already on aspirin
- no NSAID → CKD or AKI, GI bleed or ulcer, anticoagulation, heart failure, pregnancy from 20 weeks → colchicine alone, or prednisolone 0.25–0.5 mg/kg/day with cardiology once infection is excluded
- cardiology now → fever > 38 °C, large effusion or tamponade, troponin rise, immunosuppressed or anticoagulated
tension pneumothorax: treat before imaging
- needle decompression now, do not wait for a CXR → 4th or 5th intercostal space anterior to the mid-axillary line, above the rib; 2nd intercostal space mid-clavicular is the alternative
- decompression is temporary → chest drain follows → oxygen desaturation
pneumothorax, non-tension
- CXR now; size and symptoms decide observation vs chest drain, with respiratory or surgery
esophageal perforation / Boerhaave
- NPO, IV fluids; thoracic surgery and GI now
- antibiotics → piperacillin–tazobactam 4.5 g IV q6h (or 4.5 g over 4 h q8h as an extended infusion per local policy), meropenem 1 g IV q8h if shock, plus fluconazole → empiric antibiotics
- CT chest with water-soluble oral contrast confirms; no barium, no endoscopy before surgery reviews
MSK pain
- paracetamol 1 g PO q6h ± NSAID if no contraindication → analgesia
- a diagnosis after the ECG and troponin, not instead of them
pneumonia
- CXR, blood cultures, sputum; CAP or HAP (onset ≥ 48 h after admission) decides the regimen → empiric antibiotics
- sepsis criteria → fever
- shock develops → hypotension, advanced: shock
- hand over → working diagnosis, ECG and troponin times, treatments given, escalation trigger
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 |
| 2015 ESC pericardial diseases guideline (no AHA/ACC equivalent) | international guideline |
| ATLS 10th ed. needle decompression | specialty-society guidance |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
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 Oct 2026file complaint/chest-pain