Chest pain
History-taking (acronym "OLD CARTS")
Onset: Where did the pain start?
Location: Where is the pain located?
Duration: How long does the pain last? Is it continuous or intermittent?
Character: Describe the pain. Is it crushing, stabbing, or burning?
Associated symptoms: What other symptoms accompany the pain, such as nausea/vomiting, sweating, fainting, breathlessness, or cold and clammy?
Relief: Does the pain cease when you stop working or exercising? Is it alleviated by sitting forward?
Timing: Does the pain occur during specific situations?
Severity: Rate the pain on a scale of 1 to 10.
Emergency chest pain that must be ruled out
STEMI/ NSTEMI
Tension pneumothorax/ Tamponade
Aortic dissection
Blood clot (acute pulmonary embolism)/Boerhaave's syndrome (rupture of the esophagus)
Likelihood of acute MI (JAMA 2005;294(20):2623–9.)
Pain descriptor
Increase likelihood of acute myocardial infarction
Radiation to right arm or shoulder
Radiation to both arms or shoulder
Associated with exertion
Radiation to left arm
Associated with diaphoresis
Associate with nausea and vomiting
Worse than previous angina or similar to previous MI
Describe as pressure
Decrease likelihood of acute myocardial infarction
Described as pleuritic
Described as positional
Described as sharp
Reproducible with palpation
Inframammary location
Not associated with exertion
Positive likelihood Ratio (95% CI)
4.7 (1.9-12)
4.1 (2.5-6.5)
2.4 (1.5-3.8)
2.3 (1.7-3.1)
2.0 (1.9-2.2)
1.9 (1.7-2.3)
1.8 (1.6-2.0)
1.3 (1.2-1.5)
Negative likelihood Ratio (95% CI)
0.2 (0.1-0.3)
0.3 (0.2-0.5)
0.3 (0.2-0.5)
0.3 (0.2-0.4)
0.8 (0.7-0.9)
0.8 (0.6-0.9)
Acute coronary syndrome is prevalent in the general population, particularly regarding red flag symptoms such as prolonged chest pain (lasting over 15 minutes) and/or recurrent pain within an hour, which should prompt patients or others in the public to seek urgent medical assistance.
Most visceral discomfort associated with myocardial ischemia is deep, hard to pinpoint, and often diffuse. Point tenderness makes ischemia less likely. Pain radiating to below the umbilicus is less likely related to myocardial ischemia.
Chest pain has previously been categorized into "typical" and "atypical" types. Chest pain more likely related to ischemia includes 1) substernal discomfort, 2) being provoked by exertion or emotional stress, and 3) relieved by rest or nitroglycerin.
Relief from nitroglycerin does not necessarily indicate myocardial ischemia and should not be considered a diagnostic criterion. Nitrates are also used to treat esophageal pain.
Clinicians often regard atypical chest pain as less indicative of cardiac issues, which can lead to delays in diagnosis and treatment. Therefore, the descriptor ‘atypical’ should be avoided. In older adults, the clinical presentation of acute coronary syndrome (ACS) tends to be more atypical. Dyspnea is the primary symptom of these atypical presentations. The term 'possible cardiac' should be used.
Other causes of chest pain
Pericarditis
Fever and sharp chest pain radiate to the scapular ridge, increasing with inspiration and lying supine.
Pericardial friction rub is highly specific to pericarditis. The pericardial rub is variably audible during the day.
Acute aortic syndrome
The sudden onset of ripping chest pain ("the worst chest pain of my life”) radiating to the upper or lower back, especially in a hypertensive patient or someone with a known bicuspid aortic valve or aortic dilation, which raises suspicion for acute aortic syndrome.
Acute pulmonary embolism
Central pulmonary embolism can cause pain similar to that of acute coronary syndrome due to the right ventricular pressure load, leading to RV ischemia. Pleuritic chest pain can occur due to pulmonary infarction secondary to a small distal pulmonary artery (PA).
Valvular heart disease
Severe aortic stenosis and severe aortic regurgitation can lead to angina pain due to decreased coronary blood flow, with or without coronary artery stenosis. Mitral valve stenosis may also cause chest pain as a result of pulmonary hypertension and right ventricular ischemia.
Physical Examination:
-
Severe AS: Systolic murmur accompanied by a pulsus parvus et tardus. soft S2, audible S4.
-
Severe AR: Diastolic blowing murmur located to the right of sternum, with a rapid carotid upstroke.
-
Hypertrophic cardiomyopathy: Prominent a wave in jugular venous pressure, systolic murmur, audible S4, and a double or sustained apex beat.
-
Severe MS: Cv wave, loud S1, opening snap, diastolic rumbling murmur at apex, loud P2, and left parasternal heave.
Myocardiits
Fever, signs and symptoms of heart failure, S3, ventricular arrhythmia or AV block.
Esophageal rupture
Mackler's triad: vomiting followed by severe chest pain, subcutaneous emphysema, pneumothorax (20% patients), unilateral decreased or absent breath sounds.
Pneumothorax
Dyspnea and pain during inspiration, unilateral absence of breath sounds, hyperresonance upon chest wall percussion, and decreased wall movement on the affected side of the chest.
Esophagitis, peptic ulcer disease, gall bladder disease
Peptic ulcer disease: Epigastric tenderness
Gall bladder disease: Right upper quadrant tenderness, Murphy sign.
Costochondritis, Tietze syndrome
Tenderness of costochondral joints
Herpes zoster
Pain in dermatomal distribution, triggered by touch; characteristic localized, blistering, and painful rash (unilateral and dermatomal distribution).
References
Swap C, Nagurney J. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 2005;294(20):2623–9.
Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, 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):e368–454.
Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. 2023 ESC Guidelines for the management of acute coronary syndromes: Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology (ESC). European Heart Journal. 2023 Oct 7;44(38):3720–826.