Chest pain – investigation, diagnosis and treatment
How to manage a patient presenting with chest pain
- This page explains how to approach a patient with chest pain, focusing on the immediate investigations, common and important possible diagnoses, and what you should do to treat it
Is this an emergency?
- Always start with an ABCDE approach
- If the patient looks very unwell or peri-arrest ask for help early
Worrying features
- Obs: Tachycardia over 120, bradycardia, hypotension, high respiratory rate, low GCS
- Presentation: Sudden onset, sweating, nausea, vomiting, pain radiating to jaw, left arm or back
- ECG changes
Think about…
- Common
- Heart: Myocardial infarction or acute coronary syndromes (STEMI, NSTEMI, unstable angina), pericarditis
- Lungs: Pulmonary embolism, pneumonia, pneumothorax
- GI: Reflux and peptic ulcer disease
- Musculoskeletal (rule out others first)
- Uncommon but important
- Aortic dissection
- Cardiac tamponade
- Sickle-cell crisis
History
- Presenting complaint: site of onset and radiation, quality (heavy, aching, sharp, tearing), intensity (scale of 1–10), time of onset, duration, associated symptoms (sweating, nausea, palpitations, breathlessness), exacerbating or relieving factors (breathing, position, exertion, eating), recent trauma or exertion, similarity to previous episodes
- Past medical history : cardiac or respiratory problems, diabetes, reflux
- Drug history: cardiac or respiratory medications, antacids
- Family history: IHD (esp under 60 years old), premature cardiac death
- Social history: smoking, exercise tolerance
Risk factors
- Ischaemic heart disease: hypertension, high cholesterol, positive family history, smoking, diabetes, previous IHD, obesity
- PE: previous PE/DVT, immobility, use of oestrogens/OCP, recent surgery, malignancy, family history, pregnancy, hypercoagulable states, smoking, long distance travel
- GI: known GORD, known peptic ulcer, alcohol binge
Observations
- HR, BP (both arms), RR, sats, temp
Examination
- General: Pulse rate/rhythm/volume, sweating, pallor, dyspnoea, cyanosis
- Neck: Raised JVP; tracheal deviation
- Chest: Asymmetric chest expansion/percussion/breath sounds; chest wall tenderness; murmur
- Abdo: epigastric tenderness
- Legs: swollen ankles, calf pain/swelling/erythema
Investigations
- ECG
- Bloods
- FBC, U&E, LFT, D-dimer (if considering PE and low Wells score), troponin if suspected IHD
- ABG if patient acutely unwell or sats under 95%
- CXR
- Portable CXR if the patient is severely ill. Standard CXR if they can go to department
- Echo/ CT if large proximal PE or aortic root dissection suspected
- Also can echo for region wall motion abnormality in MI
Common causes of chest pain
| Diagnosis | History | Examination | Investigations |
|---|---|---|---|
| ACS (STEMI) | Sudden onset pain, radiating to left arm/jaw, >20min, breathlessness, sweating, nausea | Dyspnoea, ±arrhythmia, sweating | ST elevation or new LBBB, raised troponin. Cardiac markers are not needed to make the diagnosis of STEMI |
| ACS (NSTEMI) | Sudden onset pain, radiating to left arm/jaw, >20min, breathlessness, sweating, nausea | Dyspnoea, ±arrhythmia, sweating | ST depression, t-wave inversion; raised troponin |
| ACS (Unstable angina) | Anginal pain at rest or with raised frequency, severity or duration | Dyspnoea, ±arrhythmia, sweating | ST depression, T-wave inversion, troponin not elevated |
| Angina (stable) | Exertional pain, radiating to left arm/jaw, <20min, breathlessness, relieved by rest/GTN | Dyspnoea, tachycardia, may be normal after pain resolves | Transient ECG changes, troponin not elevated, positive stress ECG, positive coronary angiography |
| Pericarditis | May have history of viral-like illness, pleuritic pain, increased on lying, decreased by sitting forwards | May have pericardial rub, otherwise normal examinations | Saddle-shaped ST segments on most ECG leads, raised CRP |
| Aortic dissection | Sudden onset severe interscapular pain, tearing in nature, breathlessness. May have arm weakness/numbness | Tachycardia, shock, difference in brachial pulses and pressures. Limb weakness or paraesthesia | Widened mediastinum on CXR, aortic dilatation on echo/CT |
| Pulmonary embolism | Breathlessness, PE risk factors, may have pleuritic chest pain and haemoptysis | Often normal, may have evidence of DVT (swollen red leg), tachycardia, dyspnoea | ABG: low (or normal) pO2, low CO2 (hyperventilation), clear CXR. Raised D-dimer. ECG: sinus tachycardia, S1Q3T3 (rare), thrombus on echo |
| Pneumothorax | Sudden onset pleuritic pain ±trauma; tall and thin; COPD | Mediastinal shift, unequal air entry and expansion, hyperresonance | Mediastinal shift, unequal air entry and expansion, hyperresonance |
| Pneumonia | Cough, productive with coloured sputum, pleuritic pain, feels unwell | Febrile, asymmetrical air entry, coarse creps (often unilateral), dull to percussion | High white count and CRP, consolidation on CXR |
| Musculoskeletal chest pain | Lifting, impact injury, may be pleuritic, worse on palpation or movement | Tender (presence does not exclude other causes), respiratory examination normal | ECG to exclude cardiac cause, normal CXR |
| Oesophageal reflux or spasm | Previous indigestion/ reflux, known hiatus hernia, relieved by antacids | May have upper abdo tenderness, normal examinations | ECG to exclude cardiac cause, normal CXR, trial of antacids |
Treatment
- Oxygen to keep sats over 94%
- Consider IV opioids (and an antiemetic) if pain is severe
- Further treatment depends on cause
Common and important diagnoses
- If you are unable to confirm a diagnosis immediately, consider life-threatening causes and investigate until excluded:
- Cardiac ischaemia: abnormal ECG, typical history, raised cardiac markers
- PE: low sats, abnormal ECG, clinical risk, high D-dimer, positive CTPA
- Pneumothorax: mediastinal shift, decreased breath sounds, CXR
- Aortic dissection: evidence of shock, left and right systolic BP differ by >15mmHg, mediastinal widening on CXR, abnormal CT/echo