- Chest pain is a very common presenting complaint, and the most pressing concern is to rule out life-threatening causes such as acute coronary syndrome, pulmonary embolism, aortic dissection and tension pneumothorax. A thorough history is vital for differentiating between these causes and other less emergent conditions that may cause chest pain.
Causes of Chest Pain
- Stable angina
- Acute coronary syndrome - unstable angina, NSTEMI, STEMI
- Other cardiac ischaemia - vasospasm (prinzmetal angina), severe aortic stenosis, hypertensive ischaemia, rate-related ischaemia, dilated cardiomyopathy, Tako-tsubo cardiomyopathy
- Non-ischaemic - pericarditis, myocarditis, myocardial contusion
- Vascular - aortic dissection, pulmonary embolism
- Respiratory - pneumonia with pleurisy, pneumothorax, lung cancer
- Gastrointestinal - peptic ulcer, gastritis, oesophagitis, oesophageal spasm, oesophageal rupture
- Musculoskeletal - costochondritis, osteomyelitis, rib fracture, cervical spinal disease
- Psychogenic - panic disorder, malingering
History of Presenting Complaint
SiteWhere the pain is - central, the left or right side, the ribs, or generalised.
- Retrosternal chest painReflux, angina
- Pain in chest wall / ribs Suggestive of a musculoskeletal cause - unlikely to be anginal
OnsetWhether the pain began suddenly or gradually, and what the patient was doing at the time.
- Onset at restSuggestive of acute coronary syndrome over stable angina if typical ischaemic pain
- Onset during exertionSuggestive of stable angina if typical ischaemic pain
- Onset post traumaMay represent pneumothorax or rib fractures
CharacterThe type of pain - sharp, dull, tight, crushing, burning or tearing.
- Central, crushing chest painTypical of acute coronary syndrome
- Tearing pain that radiates to the backCharacteristic of aortic dissection
- Pleuritic chest painSuggestive of pneumonia, pericarditis, PE, chest wall pain (unlikely anginal)
RadiationWhether the pain radiates anywhere else, such as the shoulder, arm, jaw or back.
- Pain radiating to the shoulders / arms or jawTypical of acute coronary syndrome
- Pain radiating to the backSuggestive of aortic dissection
Associated SymptomsWhether the pain is associated with any other symptoms.
- Nausea, vomiting and diaphoresisSuggestive of angina / acute coronary syndrome
- FeversSuggestive of pneumonia, pericarditis or costochondritis
- Shortness of breathSuggestive of respiratory cause such as pneumonia, pneumothorax or PE
- CoughSuggestive of pneumonia or reflux
- Sour taste / acid refluxSuggestive of reflux pain
TimingHow long the pain has been going on for.
- Central crushing chest pain lasting >20 minutesSuggestive of acute coronary syndrome rather than stable angina
Exacerbating FactorsWhether anything makes the pain worse, such as breathing in or sitting forward.
- Exertional chest painSuggestive of cardiac pain
- Pleuritic chest painSuggestive of pneumonia, pericarditis, PE or chest wall pain (unlikely anginal)
- Brought on with foodSuggestive of reflux
- Worsened by sitting forward or lying downSuggestive of reflux
Alleviating FactorsWhether anything they've tried has improved or resolved the pain.
- Relief with GTNStrongly suggestive of cardiac ischaemia, though GTN may also relieve oesophageal pain
- Relief with reflux medsMore likely to represent reflux pain
- Relief with passing gasSuggestive of ‘pseudo-angina’ - gas in stomach or splenic flexure
- Improved with sitting forwardSuggestive of pericarditis
- How severe the pain is out of 10, with 10 being the worse possible pain.
- How the pain is impacting the patient’s life, such as work, hobbies or even mobility.
High Likelihood of Acute Coronary Syndrome
- Pressure-like sensation (e.g. tight or crushing)
- Radiating to one or both arms
- Associated with exertion, nausea, vomiting or diaphoresis
Low Likelihood of Acute Coronary Syndrome
- Stabbing pain
- Pleuritic pain
- Positional pain
- Inframammary pain
- Reproducible with palpation