Acute chest pain - Revision history

Danbot: Add verified PubMed references (PMIDs 34709879, 36241466)

2026-03-22T10:43:34Z

Add verified PubMed references (PMIDs 34709879, 36241466)

← Older revision		Revision as of 10:43, 22 March 2026
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	''See [[Acute coronary syndrome (main)]] for ACS-specific workup and risk stratification; see [[Chest pain (peds)]] for pediatric patients.''		''See [[Acute coronary syndrome (main)]] for ACS-specific workup and risk stratification; see [[Chest pain (peds)]] for pediatric patients.''
	==Background==		==Background==
	*Chest pain accounts for approximately 6-8% of all ED visits		*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"):		*The primary ED goal is to rapidly identify and treat '''immediately life-threatening causes''' ("the big 5"):
	**[[Acute coronary syndrome]] (ACS)		**[[Acute coronary syndrome]] (ACS)

Danbot: Strip excess bold text

2026-03-22T09:23:54Z

Strip excess bold text

← Older revision		Revision as of 09:23, 22 March 2026
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	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
	*~~'''~~All patients:~~'''~~		*All patients:
	**[[ECG]] - within 10 minutes of arrival; repeat if symptoms change or initially nondiagnostic		**[[ECG]] - within 10 minutes of arrival; repeat if symptoms change or initially nondiagnostic
	**[[CXR]]		**[[CXR]]
	**Vital signs including bilateral blood pressures if dissection suspected		**Vital signs including bilateral blood pressures if dissection suspected
	*~~'''~~Moderate-to-high risk or concerning features:~~'''~~		*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)		**[[Troponin]] - serial troponins (0h and 1-3h with high-sensitivity assay; 0h and 3-6h with conventional assay)
	**CBC, BMP		**CBC, BMP
	**Consider coagulation studies		**Consider coagulation studies
	*~~'''~~Additional testing based on suspicion:~~'''~~		*Additional testing based on suspicion:
	**[[D-dimer]] or [[CT-PA]] - if PE suspected (use validated pretest probability tools: Wells score, PERC rule, YEARS algorithm)		**[[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		**[[CT angiography]] of chest/abdomen/pelvis - if [[aortic dissection]] suspected
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	===Risk Stratification===		===Risk Stratification===
	*~~'''~~[[HEART Score]]:~~'''~~ Validated tool for risk stratification in undifferentiated chest pain		*[[HEART Score]]: Validated tool for risk stratification in undifferentiated chest pain
	**Score 0-3: Low risk; consider early discharge		**Score 0-3: Low risk; consider early discharge
	**Score 4-6: Moderate risk; admission/observation with serial troponins		**Score 4-6: Moderate risk; admission/observation with serial troponins
	**Score 7-10: High risk; admission with cardiology consultation		**Score 7-10: High risk; admission with cardiology consultation
	*~~'''~~[[Wells score]]:~~'''~~ For pretest probability of PE		*[[Wells score]]: For pretest probability of PE
	*~~'''~~[[PERC rule]]:~~'''~~ If low pretest probability, PERC can exclude PE without D-dimer		*[[PERC rule]]: If low pretest probability, PERC can exclude PE without D-dimer

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

	==Disposition==		==Disposition==
	*~~'''~~Admit to ICU/monitored bed:~~'''~~		*Admit to ICU/monitored bed:
	**STEMI, unstable ACS, hemodynamically significant PE, aortic dissection, pericardial tamponade		**STEMI, unstable ACS, hemodynamically significant PE, aortic dissection, pericardial tamponade
	*~~'''~~Admit/observe:~~'''~~		*Admit/observe:
	**Moderate HEART score with pending serial troponins		**Moderate HEART score with pending serial troponins
	**NSTEMI awaiting cardiology evaluation		**NSTEMI awaiting cardiology evaluation
	*~~'''~~Discharge:~~'''~~		*Discharge:
	**Low HEART score (0-3) with negative serial troponins		**Low HEART score (0-3) with negative serial troponins
	**Clear non-cardiac cause identified (e.g., musculoskeletal, GERD)		**Clear non-cardiac cause identified (e.g., musculoskeletal, GERD)

Danbot: Move calculators to own section with header (visible in TOC), expanded, before External Links

2026-03-21T15:05:36Z

Move calculators to own section with header (visible in TOC), expanded, before External Links

← Older revision		Revision as of 15:05, 21 March 2026
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	**PE ruled out with validated approach		**PE ruled out with validated approach
	**Arrange appropriate follow-up (PCP within 72 hours for intermediate-risk patients)		**Arrange appropriate follow-up (PCP within 72 hours for intermediate-risk patients)

			== Calculators ==
			{{HEART_Score_Calculator}}

	==See Also==		==See Also==
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	==References==		==References==
	<references/>		<references/>


	~~<div class="mw-collapsible mw-collapsed" style="border:1px solid #aaa; padding:5px; margin-top:10px;">~~
	~~<div style="font-weight:bold;">📊 HEART Score Calculator [show]</div>~~
	~~<div class="mw-collapsible-content">~~
	~~{{HEART_Score_Calculator}}~~
	~~</div>~~
	~~</div>~~
	[[Category:Cardiology]]		[[Category:Cardiology]]
	[[Category:Symptoms]]		[[Category:Symptoms]]

Danbot: Add HEART Score calculator (collapsible)

2026-03-21T13:49:46Z

Add HEART Score calculator (collapsible)

← Older revision		Revision as of 13:49, 21 March 2026
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	<references/>		<references/>


			<div class="mw-collapsible mw-collapsed" style="border:1px solid #aaa; padding:5px; margin-top:10px;">
			<div style="font-weight:bold;">📊 HEART Score Calculator [show]</div>
			<div class="mw-collapsible-content">
			{{HEART_Score_Calculator}}
			</div>
			</div>
	[[Category:Cardiology]]		[[Category:Cardiology]]
	[[Category:Symptoms]]		[[Category:Symptoms]]

Danbot: Comprehensive expansion: EM approach with the big 5, structured evaluation, HEART score risk stratification, and disposition criteria

2026-03-20T23:08:28Z

Comprehensive expansion: EM approach with the big 5, structured evaluation, HEART score risk stratification, and disposition criteria

← Older revision		Revision as of 23:08, 20 March 2026
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	''See [[Acute coronary syndrome (main)]] for ACS specific workup and risk stratification; see [[Chest pain (peds)]] for pediatric patients.''		''See [[Acute coronary syndrome (main)]] for ACS-specific workup and risk stratification; see [[Chest pain (peds)]] for pediatric patients.''
	==Background==		==Background==
			*Chest pain accounts for approximately 6-8% of all ED visits
			*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==
	{{Clinical features ACS}}		{{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==		==Differential Diagnosis==
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	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
	~~====Younger~~ patients~~/less concerning story====~~		*'''All patients:'''
	*[[ECG]]		**[[ECG]] - within 10 minutes of arrival; repeat if symptoms change or initially nondiagnostic
	*[[CXR]]		**[[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

	===~~=Older patients/more concerning story=~~===		===Risk Stratification===
	*[[~~ECG~~]]		*'''[[HEART Score]]:''' Validated tool for risk stratification in undifferentiated chest pain
	*~~CBC~~		**Score 0-3: Low risk; consider early discharge
	*~~Chemistry~~		**Score 4-6: Moderate risk; admission/observation with serial troponins
	*PT/~~PTT~~		**Score 7-10: High risk; admission with cardiology consultation
	*~~[[Troponin]]~~		*'''[[Wells score]]:''' For pretest probability of PE
	*~~[[CXR]]~~		*'''[[PERC rule]]:''' If low pretest probability, PERC can exclude PE without D-dimer
	*Consider:
	**[[BNP]]
	**[[D-dimer]] vs. CTA chest

	~~===Diagnosis===~~
	''~~Consider differential diagnosis (see above) and rule out emergent causes~~''
	*[[~~ACS~~]]: ~~Consider using [https://www.mdcalc.com/heart-pathway-early-discharge-acute-chest-pain HEART Pathway]~~
	*[[PE]]: ~~See [[Pulmonary_embolism#Workup_by_Pretest_Probability\|Pulmonary embolism by~~ pretest probability]]

	==Management==		==Management==
	*~~Based~~ on underlying cause		*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==		==Disposition==
	*~~Based on underlying cause~~		*'''Admit to ICU/monitored bed:'''
	*HEART score ~~may assist in determining low~~ risk ~~discharge vs admission for further ACS evaluation~~		**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)

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

	==References==		==References==
	<references/>		<references/>

	[[Category:Cardiology]]		[[Category:Cardiology]]
	[[Category:Symptoms]]		[[Category:Symptoms]]

Nheft: /* Videos */

2024-05-11T06:39:02Z

Videos

← Older revision		Revision as of 06:39, 11 May 2024
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	*[[Cocaine chest pain]]		*[[Cocaine chest pain]]
	*[[HEART Score]]		*[[HEART Score]]

	~~==Videos==~~
	~~{{#widget:YouTube\|id=ZxKvGg_RkfA}}~~

	~~{{#widget:YouTube\|id=cdSXjp1UX28}}~~

	==References==		==References==

Masoodrm: /* Disposition */

2021-04-15T15:15:01Z

Disposition

← Older revision		Revision as of 15:15, 15 April 2021
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	==Disposition==		==Disposition==
	*Based on underlying cause		*Based on underlying cause
			*HEART score may assist in determining low risk discharge vs admission for further ACS evaluation

	==See Also==		==See Also==

ClaireLewis: /* See Also */

2019-09-23T23:36:20Z

Mceledon83: /* Video */

2018-08-08T23:35:18Z

Video

← Older revision		Revision as of 23:35, 8 August 2018
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	*[[HEART Score]]		*[[HEART Score]]

	==~~Video~~==		==Videos==
	{{#widget:YouTube\|id=ZxKvGg_RkfA}}		{{#widget:YouTube\|id=ZxKvGg_RkfA}}

Mceledon83: /* Video */

2018-08-08T23:24:01Z

Video

← Older revision		Revision as of 23:24, 8 August 2018
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	==Video==		==Video==
	{{#widget:YouTube\|id=ZxKvGg_RkfA}}		{{#widget:YouTube\|id=ZxKvGg_RkfA}}

			{{#widget:YouTube\|id=cdSXjp1UX28}}

	==References==		==References==

← Older revision		Revision as of 23:36, 23 September 2019
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	==See Also==		==See Also==
	*[[Acute Coronary Syndrome (Main)]]		*[[Acute Coronary Syndrome (Main)]]
			*[[Chest pain]]
	*[[Chest Pain (Peds)]]		*[[Chest Pain (Peds)]]
	*[[Cocaine chest pain]]		*[[Cocaine chest pain]]