Chest Pain
A structured approach to chest pain — rule out the can’t-miss diagnoses first, then risk-stratify and disposition.
Learning Objectives
- 1.Prioritize the can’t-miss causes of chest pain before benign ones.
- 2.Take a focused history and choose the right initial workup.
- 3.Risk-stratify and decide disposition (emergent vs urgent vs elective).
- 4.Recognize when chest pain requires immediate escalation.
Overview
Chest pain is the highest-stakes complaint in cardiology because the same symptom spans benign and lethal causes. The disciplined approach is always the same: stability, then the can’t-miss list, then a focused history/EKG/troponin, then risk-stratified disposition.
Why this matters
Missed ACS, dissection, and PE are among the most consequential errors in medicine. Structure — not pattern-guessing — is what keeps these from slipping through.
The can’t-miss list
- •Acute coronary syndrome (STEMI / NSTEMI / unstable angina).
- •Aortic dissection (tearing/migrating pain, BP/pulse differential).
- •Pulmonary embolism (pleuritic, dyspnea, VTE risk factors).
- •Tension pneumothorax and esophageal rupture (non-cardiac but lethal).
- •Pericarditis/myopericarditis and tamponade.
Focused history
- •Character/exertional relationship/radiation/trend (crescendo?).
- •Associated diaphoresis, dyspnea, nausea, syncope.
- •Dissection clues: tearing, migrating to back, sudden maximal onset.
- •PE clues: pleuritic pain, dyspnea, immobility/surgery/malignancy/prior VTE.
- •Cardiac history and ASCVD risk factors.
Exam and immediate data
- •Vitals including bilateral BP when dissection is considered; perfusion.
- •EKG promptly (and compare with prior) — the single most time-critical test.
- •High-sensitivity troponin, interpreted as a trend with the story.
- •Exam: murmurs, rubs, signs of HF, unilateral leg findings (PE/DVT).
Risk stratification & disposition
- •STEMI / dynamic ischemia → activate cath-lab pathway, escalate now.
- •Validated tools (e.g., HEART score) help stratify undifferentiated chest pain.
- •High-risk features or rising troponin → admit / urgent evaluation.
- •Low-risk, reassuring serial workup → consider outpatient functional testing.
Initial management (per protocol, with the physician)
- •ACS pathway care (e.g., aspirin) per institutional protocol when indicated.
- •Do not give nitrates without checking BP and recent PDE5-inhibitor use.
- •Stabilize and escalate unstable patients before completing a full workup.
Red flags / escalation
- •Ongoing pain with diaphoresis/dyspnea; STEMI on EKG.
- •Tearing/migrating pain or inter-arm BP differential.
- •Hemodynamic instability or syncope with chest pain.
Escalate immediately
Active ischemia, dissection concern, or instability are physician-now situations — activate the appropriate pathway rather than continuing an elective workup.
Common beginner mistakes
- •Using a normal EKG/first troponin to exclude ACS in a high-risk story.
- •Anchoring on "GERD/anxiety/musculoskeletal" before excluding the can’t-miss list.
- •Sending a high-risk patient to an elective stress test.
- •Forgetting dissection (it doesn’t always look like ACS).
Documentation pearls
- •Document the can’t-miss diagnoses considered, the risk stratification, the EKG/troponin interpretation, and the disposition rationale.
Nurse / MA workflow connection
- •MA red-flag recognition and rapid EKG, plus nurse triage, get the right patient to you fast — active chest pain is escalated immediately.
Tools
- •HEART, TIMI, and GRACE scores support risk stratification (see Clinical Tools).
Mini cases
58-year-old, 1 hour of pressure-like chest pain, diaphoretic; EKG shows anterior ST elevation.
Disposition?
Show answer
Anterior STEMI — activate the cath-lab/STEMI pathway and escalate to the physician immediately, begin protocolized care. No stress test, no waiting for troponin to "confirm."
70-year-old with sudden severe tearing chest pain radiating to the back, BP 180/100 right arm and 140/80 left arm.
What must you not miss?
Show answer
Aortic dissection — the inter-arm BP differential and tearing/radiating pain are classic. Escalate emergently; this is not an ACS-only pathway and is rapidly fatal if missed.