This document provides guidance on evaluating and diagnosing the cause of chest pain. It notes that the majority of chest pain is non-cardiac in origin but can be disabling. A thorough history, physical exam, ECG and imaging can identify most causes, including life-threatening ones like myocardial infarction that require immediate treatment. The description of chest pain symptoms and related factors can provide clues to potential etiologies such as cardiac, pulmonary, gastrointestinal or musculoskeletal origin.

2.  Symptom is usually of benign etiology which
may be functionally disabling.
 Correct diagnosis is often derived from detailed
history, specific physical findings,
electrocardiogram, chest x ray
 60% chest pain are organic- due to
gastrointestinal or pulmonary disease
 36%- musculoskeletal chest pain
 11%- stable angina . 1 %- unstable angina or MI

3.  Chest pain due to MI, pul.embolus, aortic
dissection or tension pneumothorax result in
sudden death.
 Stabilization of pt include placement of cardiac
monitoring, supplementary oxygen
 Electrocardiogram & blood sample for cardiac
enzymes should be obtained if possible.
 Pts experiencing an acute coronary syndrome
should chew a 325mg aspirin tablet. Sublingual
nitroglycerin can be given

4.  Evaluation of new onset chest pain in stable
individuals should begin with ruling out life
threatening causes.
 Clinical evaluation- ECG testing, exercise stress
testing angiography etc.
 History, physical examn, electrocardiogram, CXR
can accurately diagnose most causes of chest
pain.
 Chest pain history is less useful in pts with acute
coronary syndrome.

5. Description of chest pain:
 Due to MI – differs depending on pt’s age, gender &
presence of comorbid conditions (DM)
 Typical descriptions-Squeezing, tightness, pressure,
constriction, strangling, burning, heartburn, fullness in
chest, lump in throat,heavy wt. on chest &
toothache(radiation to lower jaw)
Quality of pain:
 Pleuritic, positional, sharp, reproducible with
palpation- less likelihood of ACS
 Radiating to shoulder/arm, precipitated by exersion-likelihood
of ACS ( weakly associated)
 In some cases, pt cannot qualify chest pain but places
fist in centre of chest( levine sign)
 Acute chest pain with ripping tearing-acute aortic
dissection

6. Region/location of pain:
 Ischemic pain-difficult to localize. Indicate large
area of discomfort
 Localized to small area on chest-more likely of
chest wall or pleural origin
 Placing fist in centre of chest-ischemic pain
 Pointing at a single location with one finger-MI
Radiation:
 MI-radiates to neck, throat, lower jaw, teeth or
shoulder.
 Radiating to left arm-classically associated with
coronary ischemia

7.  Acute cholecystitis –can radiate to rt.shoulder.
 Aortic dissection- pain radiates b/w scapulae.
 Pericarditis- pain radiates to one or both
trapezius
 Cervical radiculopathy may present with chest,
upper back or upper extremity pain.
Temporal elements:
 Pain associated with pneumothorax, aortic
dissection or pul.embolism have abrupt onset
with great intensity at beginning
 Onset of ischemic pain is often gradual with
increasing intensity
 Non traumatic musculoskeletal pain has vague
onset

8. Provocation:
 Discomfort that occurs with eating is suggestive
of GI disease
 Chest pain provoked by exertion is classical
symptom of angina
 Other factors that may provoke ischemic pain
include cold, emotional stress, meals etc
 Pain worsening by swallowing is likely of
esophageal origin
 Pain exacerbated by body position, movement or
deep breathing suggests musculoskeletal origin
 Pleuritic chest pain is worsened by respn or may
be exacerbated when lying down. Seen in
pul.embolism, pneumothorax, pneumonia etc

9. Palliation:
 Pain palliated by antacid or food is likely of GI
origin
 Pain responding to sublingual nitroglycerin is
thought to have cardiac etiology or due to
esophageal spasm
 Pain that abates with cessation of activity-ischemic
origin
 Pain of pericarditis improves with sitting up &
sitting up
Severity:
 Not useful in presence of CHD

10. Associated symptoms:
 Belching, bad taste in mouth & difficulty in
swallowing-esophageal disease.
 Indigestion may also be seen with myocardial
ischemia
 Vomiting can be seen in MI
 Diaphoresis more frequently associated with MI
Dyspnea:
 Exertional dyspnea with chest pain may be due
to MI
 Dyspnea occuring concurrently with chest pain
may be due to pul.disorders-pathology of airway,
lung parenchyma or pul. vasculature

11. Cough:
 D/d of chest pain with cough include infections, CCF,
pul.embolus & neoplasm
 Cough, hoarseness, or wheezing- may be due to GI
disease
Syncope:
 Pts. with MI- describe presyncope
 Chest pain with syncope – concern for aortic
dissection, pul.embolus, ruptured aortic aneurysm or
aortic stenosis
Palpitations:
 Pt.with ischemia-abnormal awareness of sinus
rhythm
 Atrial fibrillations-chronic CHD
 Palpitations due to new atrial fibrillations-pul.
embolism

12. Psychiatric symptoms:
 Panic disorders, generalized anxiety, depression
may be seen in pts with chest pain
Constitutional symptoms:
 Fatigue-seen in MI
 Pleuritic chest pain with systemic symptoms-evaluated
for cause of serositis like SLE of
familial mediterranean fever
 True chest wall pain is not usually associated
with systemic symptoms. Exceptions include pain
due to chest wall neoplasm, intrathoracic trauma
& constitutional symptoms or rash of herpes
zoster

13. Risk factors:
 Presence of hyperlipidemia, LVH, or family
history of premature CHD increases risk for MI
 HTN-risk factor for CHD & aortic dissection
 Smoking- non specific risk factor for CHD,
thromboembolism, aortic, pneumothorax &
pneumonia
 Cocaine use- increases suspicion of MI, pul.HTN,
& acute pul. Syndrome
 Recent infection especially viral may precede an
episode of pericarditis or myocarditis.
 Other risk factors for pericarditis include h/o
chest trauma, autoimmune disease, recent MI or
cardiac surgery & drug use
 Age > 40 - imp.risk factor for CHD

14.  Men > 60ys- aortic dissection
 Young men- spontaneous pneumothorax
Physical examination:
 General appearance suggests severity &
seriousness of symptoms
 Vital signs provide clues to clinical significance of
pain
 Cardiac examination should be performed to
establish presence of pericardial rub or signs of
acute aortic insufficiency or aortic stenosis
 Detection of presence of wheeze, crackles or
evidence of consolidation
 Abdominal examination- rt. Upper quadrant,
epigastrium & abd. Aorta.

15. Ancillary studies:
 ECG & CXR may support initial diagnosis
 D-dimer test for pul.embolism
 Cardiac troponin- for MI
 Other investigations-exercise ECG, myocardial
perfusion, echocardiographic stress testing, bone
or chest CT etc

16. Step 1: consider life threatening causes
 Emergent care should be provided in pts who
appear seriously ill or in pts with critical
noncoronary diagnosis
Step 2: emergent care not needed. in pts in
whom diagnosis of stable CHD appears likely
Step 3: evaluate pt for CHD & consider starting
outpatient management( aspirin, b-blockers,
nitroglycerin) or admitting pt.if symptoms are
progressive
Step 4:evaluate pt. for GI diseases

17. Step 5: symptoms not suggestive of angina
Step 5a:for pts who are not felt to have
ischemic etiology but have significant risk factors
for CHD. Should be evaluated for CHD
Step 5b: if symptoms suggest musculoskeletal
etiology, trail of NSAID’s is given. If pain persists
consider rib films, bone scan, CXR or chest CT.
Step 5c:if symptoms suggest GI etiology,
evaluate for GI diseases
Step 5d:if symptoms suggest psychogenic
etiology, evaluate for psychosocial source of chest
pain
Step 5e: consider chest anatomy or other less
common causes of chest pain

18. Step 6:if chest pain persists & if evaluation for
CHD, GI causes, psychogenic pain & other causes
have not all been performed, those evaluations
should now be undertaken
Step 7:if diagnostic evaluations are –ve,pt.
likely has chronic idiopathic chest pain.
Step 8: when cause of chest pain is diagnosed,
proceed with therapy or additional evaluation

19.  Development of any one of the following should
alerts likelihood of ACS in pt who does not have
clear ST elevation:
Worsening in frequency,intensity, duration &
timing of prior symptoms
 New onset of SOB, nausea, sweating, extreme
fatigue in pt without history of CV disease
 New findings or worsening of murmur,
hypotension, rales or pul. Edema
 Transient ST deviation or T wave inversion

20.  Features that need to be considered but not as
predictive as high likelihood includes:
 Age > 70 yrs
 DM
 Extracardiac vascular disease
 Fixed Q wave or ST depression(0.5-1 mm) or T
wave inversion(>1 mm)
 Emergent hospitalization- MI or unstable angina
 Exercise stress testing- suspected IHD, unstable
coronary syndrome
 Acute rest radionuclide myocardial perfusion
imaging(rMPI)-sensitive for detecting acute MI