View source for Acute chest pain

''See [[Acute coronary syndrome (main)]] for ACS-specific workup and risk stratification; see [[Chest pain (peds)]] for pediatric patients.''
==Background==
*Chest pain accounts for approximately 6-8% of all ED visits<ref>Gulati M, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Nov 30;144(22):e368-e454. PMID 34709879</ref><ref>Kontos MC, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Nov 15;80(20):1925-1960. PMID 36241466</ref>
*The primary ED goal is to rapidly identify and treat '''immediately life-threatening causes''' ("the big 5"):
**[[Acute coronary syndrome]] (ACS)
**[[Pulmonary embolism]] (PE)
**[[Aortic dissection]]
**[[Tension pneumothorax]]
**[[Esophageal perforation]] (Boerhaave syndrome)
*Most chest pain in the ED is ultimately non-cardiac, but the evaluation is driven by the need to exclude dangerous etiologies

==Clinical Features==
{{Clinical features ACS}}
*Key historical features to assess:
**Quality: crushing/pressure (ACS), tearing/ripping (dissection), pleuritic/sharp (PE, pericarditis, pneumothorax)
**Radiation: jaw/arm (ACS), back (dissection), shoulder (pericarditis)
**Onset: sudden (PE, dissection, pneumothorax) vs gradual (ACS, musculoskeletal)
**Associated symptoms: diaphoresis, dyspnea, nausea/vomiting, syncope
**Risk factors: cardiac history, DVT/PE risk factors, cocaine use, connective tissue disease, recent procedure
*Red flags:
**Hemodynamic instability
**New ECG changes (ST elevation/depression, new LBBB)
**Unequal blood pressures or pulses (aortic dissection)
**Tracheal deviation, absent breath sounds (tension pneumothorax)
**Subcutaneous emphysema (pneumomediastinum, esophageal perforation)

==Differential Diagnosis==
{{Chest Pain DDX}}

==Evaluation==
===Workup===
*All patients:
**[[ECG]] - within 10 minutes of arrival; repeat if symptoms change or initially nondiagnostic
**[[CXR]]
**Vital signs including bilateral blood pressures if dissection suspected
*Moderate-to-high risk or concerning features:
**[[Troponin]] - serial troponins (0h and 1-3h with high-sensitivity assay; 0h and 3-6h with conventional assay)
**CBC, BMP
**Consider coagulation studies
*Additional testing based on suspicion:
**[[D-dimer]] or [[CT-PA]] - if PE suspected (use validated pretest probability tools: Wells score, PERC rule, YEARS algorithm)
**[[CT angiography]] of chest/abdomen/pelvis - if [[aortic dissection]] suspected
**[[BNP]]/NT-proBNP - if [[CHF]] suspected
**[[Bedside echocardiography|Point-of-care echo]] - for pericardial effusion, RV strain, wall motion abnormalities, aortic root dilation

===Risk Stratification===
*[[HEART Score]]: Validated tool for risk stratification in undifferentiated chest pain
**Score 0-3: Low risk; consider early discharge
**Score 4-6: Moderate risk; admission/observation with serial troponins
**Score 7-10: High risk; admission with cardiology consultation
*[[Wells score]]: For pretest probability of PE
*[[PERC rule]]: If low pretest probability, PERC can exclude PE without D-dimer

==Management==
*Treat based on underlying cause:
**[[ACS]]: ASA, anticoagulation, cardiology consultation; PCI for STEMI (see [[ST-segment elevation myocardial infarction]])
**[[PE]]: Anticoagulation; thrombolytics for massive PE (see [[Pulmonary embolism]])
**[[Aortic dissection]]: HR and BP control; emergent surgical consultation for Type A (see [[Nontraumatic thoracic aortic dissection]])
**[[Tension pneumothorax]]: Needle decompression followed by chest tube
**[[Pericardial tamponade]]: Pericardiocentesis
*Pain control: Avoid NSAIDs if ACS suspected; nitroglycerin for ischemic pain (avoid in RV infarct, recent PDE5 inhibitor use, hypotension)

==Disposition==
*Admit to ICU/monitored bed:
**STEMI, unstable ACS, hemodynamically significant PE, aortic dissection, pericardial tamponade
*Admit/observe:
**Moderate HEART score with pending serial troponins
**NSTEMI awaiting cardiology evaluation
*Discharge:
**Low HEART score (0-3) with negative serial troponins
**Clear non-cardiac cause identified (e.g., musculoskeletal, GERD)
**PE ruled out with validated approach
**Arrange appropriate follow-up (PCP within 72 hours for intermediate-risk patients)

== Calculators ==
{{HEART_Score_Calculator}}

==See Also==
*[[Acute coronary syndrome (main)]]
*[[ST-segment elevation myocardial infarction]]
*[[Pulmonary embolism]]
*[[Nontraumatic thoracic aortic dissection]]
*[[Pericarditis]]
*[[HEART Score]]
*[[Chest pain (peds)]]
*[[Cocaine chest pain]]

==References==
<references/>
[[Category:Cardiology]]
[[Category:Symptoms]]