Red flags
- Crushing central chest pain, radiating to arm/jaw, +/- diaphoresis/nausea - ACS until proven otherwise
- Sudden tearing pain radiating to the back, unequal BP/pulses between arms - aortic dissection
- Pleuritic pain + dyspnoea + risk factors (immobility, malignancy, recent surgery) - PE
- Sudden pleuritic pain + dyspnoea in a tall thin young man, or known COPD - pneumothorax
- Chest pain + fever + tachycardia/hypotension - consider pericarditis with tamponade, or an infective source
- Haemodynamic instability, new murmur, or signs of heart failure with chest pain - mechanical complication (papillary muscle rupture, VSD post-MI)
Differential by mechanism
Cardiac
- ACS - STEMI, NSTEMI, unstable angina
- Stable angina - exertional, relieved by rest/GTN
- Pericarditis - sharp, pleuritic, positional (worse lying flat, relieved sitting forward), preceding viral illness
- Aortic dissection
- Myocarditis
Pulmonary
- PE, pneumothorax, pneumonia, pleurisy
GI
- GORD/oesophageal spasm (can closely mimic cardiac pain), peptic ulcer, oesophageal rupture (Boerhaave - after vomiting, subcutaneous emphysema), biliary colic/cholecystitis
Musculoskeletal / other
- Costochondritis (reproducible on palpation), rib fracture, muscle strain
- Herpes zoster (dermatomal, precedes rash)
- Anxiety/panic disorder - diagnosis of exclusion after organic causes addressed
Focused history
Characterise
- Site, character (crushing vs sharp vs tearing vs burning), radiation, onset (sudden vs gradual), duration
- Aggravating/relieving - exertion (angina), position/inspiration (pericarditis/pleurisy), food/lying flat (GORD), palpation (musculoskeletal)
- Associated symptoms - dyspnoea, diaphoresis, nausea, syncope, palpitations, cough, fever
Risk stratification
- Cardiac risk factors - age, sex, smoking, diabetes, hypertension, dyslipidaemia, family history, known CAD
- VTE risk factors - immobility, malignancy, recent surgery, prior VTE, OCP/HRT
- Dissection risk factors - hypertension, Marfan/connective tissue disease, bicuspid aortic valve, cocaine use
Focused examination
- Vital signs - BP in both arms (dissection), HR, RR, SpO2, temperature
- Cardiac - murmurs (new murmur post-MI or in dissection with AR), pericardial rub, signs of heart failure, JVP
- Respiratory - reduced breath sounds/hyperresonance (pneumothorax), consolidation, pleural rub
- Palpate chest wall for reproducible tenderness
- Abdominal exam if GI cause suspected
- Calf swelling/tenderness if PE suspected
Investigation strategy
First-line for all
- 12-lead ECG within 10 minutes of presentation if ACS possible - ST elevation/depression, T wave inversion, new LBBB, low-voltage/electrical alternans (tamponade), widespread saddle ST elevation + PR depression (pericarditis)
- High-sensitivity troponin - serial (0h/1h or 0h/2h per local rapid-rule-out protocol)
- CXR - widened mediastinum (dissection), pneumothorax, consolidation, cardiomegaly/effusion
Risk-stratified further testing
- HEART score or similar validated tool to stratify need for further testing/admission in undifferentiated chest pain
- CT pulmonary angiogram if PE likely (Wells score + D-dimer to select)
- CT aortogram if dissection suspected - do not delay for other tests
- Bedside echo - pericardial effusion/tamponade, regional wall motion, aortic root
- Functional/anatomical testing (CT coronary angiogram, stress testing) for suspected stable angina after ACS excluded
Management
Immediate, before diagnosis fully confirmed
- IV access, continuous monitoring, oxygen only if hypoxic (not routine)
- Analgesia - GTN + opioid if needed (avoid GTN if suspected dissection until BP controlled, or if inferior/RV infarct with hypotension)
By confirmed diagnosis
- STEMI - immediate reperfusion (primary PCI preferred, door-to-balloon target; thrombolysis if PCI unavailable within target time)
- NSTEACS - dual antiplatelet + anticoagulation, risk-stratify timing of angiography (immediate if very high-risk features, early invasive otherwise)
- Aortic dissection - urgent BP/HR control (beta-blocker first to limit shear stress), emergency surgery for Type A, medical management +/- endovascular repair for uncomplicated Type B
- PE - anticoagulation, thrombolysis if massive/haemodynamically unstable
- Pericarditis - NSAID + colchicine; treat underlying cause; avoid intense exercise until resolved
- Pneumothorax - observation (small, stable), needle decompression/chest drain (large, tension)
- Low-risk, non-cardiac chest pain - outpatient follow-up, address anxiety if relevant, do not over-investigate once organic causes reasonably excluded
Traps
- Giving GTN and antiplatelets before excluding dissection in atypical presentations - always consider dissection when the pain is tearing/sudden/maximal at onset
- Anchoring on GORD/musculoskeletal pain in a patient with cardiac risk factors - a reproducible-on-palpation pain does not exclude concurrent ACS
- Missing pericarditis features (positional, pleuritic, preceding viral illness, PR depression) and treating as ACS or vice versa
- Using a single troponin to rule out ACS - serial sampling per protocol is required
- Forgetting BP in both arms when dissection is a possibility
- Discharging a low-risk score chest pain patient without addressing modifiable cardiac risk factors and safety-netting
Talk track
1. Rule out the immediately life-threatening five
- "ACS, dissection, PE, tamponade, tension pneumothorax - I actively exclude each before relaxing."
2. ECG and troponin drive the initial pathway
- "ECG within 10 minutes, serial high-sensitivity troponin - that's the backbone regardless of what else I'm considering."
3. The character and context often point straight to the answer
- "Tearing and sudden makes me think dissection; positional and pleuritic makes me think pericarditis."
4. Risk-stratify before discharging
- "A validated score like HEART tells me who needs further testing and who can go home safely."
5. Treat the confirmed diagnosis specifically
- "Reperfusion for STEMI, BP control first for dissection - the initial cocktail isn't one-size-fits-all."
8 of 8 sections written · drafted 2026-09-13