Chest pain: workup and approach
Acute chest pain in an adult. First job is to exclude the six immediate killers (ACS, aortic dissection, PE, tension pneumothorax, tamponade, esophageal rupture), then risk-stratify for ACS with serial high-sensitivity troponin.
Presenting complaint
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- 2025 ACC/AHA ACS guideline: ticagrelor or prasugrel preferred over clopidogrel in NSTE-ACS; invasive strategy for intermediate- and high-risk patients, radial access preferred
- SENIOR-RITA (2024): routine invasive strategy for NSTEMI in patients ≥75 did not reduce cardiovascular death or MI; assess frailty and individualize
- REDUCE-AMI (2024): routine beta-blocker after MI with EF ≥50% did not reduce death or reinfarction
- 2021 AHA/ACC chest pain guideline: use high-sensitivity troponin pathways and validated risk tools; describe pain as cardiac, possibly cardiac or noncardiac rather than 'atypical'
Differential diagnoses
- Acute coronary syndrome (STEMI, NSTEMI, unstable angina)
- Aortic dissection
- Pulmonary embolism
- Tension pneumothorax
- Pericarditis or cardiac tamponade
- Esophageal rupture (Boerhaave)
- Pneumonia or pleuritis
- GERD, esophageal spasm
- Musculoskeletal chest wall pain
- Anxiety or panic (diagnosis of exclusion)
02Assess
Risk scores and decision tools
- HEART score: 0–3 low risk for 6-week MACE when serial troponins are negative
- High-sensitivity troponin 0/1-hour or 0/2-hour algorithm per your lab
- TIMI or GRACE score in confirmed NSTE-ACS to time angiography
- Aortic Dissection Detection Risk Score (ADD-RS) with D-dimer when dissection is possible
- Wells score and PERC rule when PE is possible
Key history questions
- Character, radiation, onset (sudden tearing pain suggests dissection)
- Exertional vs pleuritic vs positional (sitting forward relieves pericarditis)
- Associated dyspnea, diaphoresis, syncope, nausea
- Cardiac risk factors: diabetes, HTN, smoking, lipids, family history, cocaine
- VTE risk: recent surgery, immobility, malignancy, prior VTE, estrogen
- Recent vomiting (Boerhaave) or viral illness (pericarditis/myocarditis)
Examination findings
- Vitals in both arms (>20 mmHg difference suggests dissection)
- New murmur (aortic regurgitation in dissection, MR in ischemia)
- Pericardial rub; JVP, muffled heart sounds, pulsus paradoxus
- Unilateral absent breath sounds, tracheal deviation
- Calf swelling or tenderness
- Reproducible chest wall tenderness (does not exclude ACS)
03Investigate
Initial investigations
- 12-lead ECG within 10 minutes; repeat with ongoing pain
- High-sensitivity troponin at 0 and 1-3 h per local pathway
- CBC, BMP, magnesium, coagulation, lipase
- Chest X-ray
- Point-of-care ultrasound for effusion, RV strain, pneumothorax
Advanced investigations
- CT aortogram if dissection suspected
- CTPA if PE likely after Wells / D-dimer
- Echocardiogram for wall motion, effusion, valve disease
- Coronary CT angiography or stress testing in low-to-intermediate risk
- Invasive coronary angiography for STEMI or high-risk NSTE-ACS
04Treat
Immediate management
- STEMI: activate cath lab; primary PCI target door-to-balloon under 90 minutes
- Aspirin 162-325 mg chewed if ACS suspected and dissection not suspected
- Oxygen only if SpO2 below 90%
- Sublingual nitroglycerin for ischemic pain unless hypotensive, RV infarct or recent PDE5 inhibitor
- Suspected dissection: no antithrombotics; IV beta-blocker to HR <60 and SBP 100-120; urgent CT surgery
First-line treatment
- NSTE-ACS: aspirin plus a P2Y12 inhibitor (ticagrelor 180 mg load then 90 mg twice daily preferred; prasugrel at PCI unless prior stroke/TIA) with parenteral anticoagulation
- High-intensity statin (atorvastatin 80 mg); add ezetimibe or other nonstatin if LDL-C ≥70 mg/dL on maximum statin
- Beta-blocker for reduced EF, ongoing ischemia, arrhythmia or hypertension; not routinely required when EF is preserved
- Pericarditis: NSAID plus colchicine 0.6 mg twice daily (once daily if <70 kg) for 3 months
Second-line treatment
- Early invasive strategy (within 24 h) for high-risk NSTE-ACS
- IV heparin plus thrombolysis pathway if PCI not available for STEMI
Specialist referrals
- Cardiology for ACS, positive troponin, new arrhythmia or LV dysfunction
- Cardiothoracic surgery for type A dissection or esophageal rupture
- Gastroenterology if esophageal cause suspected after cardiac work-up
05Disposition
Admission criteria
- Ischemic ECG changes or rising troponin
- HEART score 4 or more
- Any life-threatening alternative diagnosis
- Hemodynamic instability or arrhythmia
Safe discharge criteria
- HEART score 0-3 with negative serial hs-troponin
- Normal ECG and pain resolved
- Alternative benign diagnosis established
- Outpatient follow-up arranged within 72 h if cardiac testing pending
Follow-up timing
- Primary care or chest pain clinic within 72 h after low-risk discharge
- Cardiology review 1-2 weeks after ACS
Patient instructions
- Call 911 for recurrent pain lasting over 5 minutes or pain with breathlessness, sweating or fainting
- Avoid strenuous exertion until reviewed
Monitoring
- Continuous telemetry while ACS not excluded
- Serial ECGs with recurrent pain
- Repeat troponin per protocol
Clinical pearls and pitfalls
- A normal first troponin does not exclude MI if pain began under 3 h ago
- Women, older adults and people with diabetes more often present atypically
- Use the HEART score only in patients without STEMI
RefGuidelines and landmark evidence
- GuidelineAHA/ACC – Guideline for the Evaluation and Diagnosis of Chest Pain (2021)PubMed
- GuidelineACC/AHA/ACEP/NAEMSP/SCAI – Guideline for the Management of Acute Coronary Syndromes (2025)PubMed
- GuidelineACC/AHA – Guideline for the Diagnosis and Management of Aortic Disease (2022)PubMed
- TrialHEART Pathway randomized trial (Mahler et al., 2015)PubMed
- TrialSENIOR-RITA: invasive vs conservative strategy in older adults with NSTEMI (2024)PubMed
- TrialREDUCE-AMI: beta-blockers after MI with preserved EF (2024)PubMed
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.